| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,090 |
1,090 |
$61K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
634 |
239 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
1,259 |
1,259 |
$36K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
276 |
130 |
$27K |
| D0274 |
Bitewings - four radiographic images |
618 |
618 |
$25K |
| D0330 |
Panoramic radiographic image |
168 |
168 |
$9K |
| D2335 |
|
46 |
12 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
328 |
328 |
$5K |
| D1120 |
Prophylaxis - child |
101 |
101 |
$4K |
| D9110 |
|
56 |
54 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
15 |
15 |
$186.30 |