| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
435 |
410 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
745 |
713 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
262 |
135 |
$14K |
| D1110 |
Prophylaxis - adult |
241 |
236 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
646 |
617 |
$8K |
| D0274 |
Bitewings - four radiographic images |
299 |
293 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
110 |
63 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
791 |
289 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
407 |
393 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
99 |
97 |
$2K |
| D0330 |
Panoramic radiographic image |
52 |
52 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$637.00 |