| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
864 |
855 |
$54K |
| D0120 |
Periodic oral evaluation - established patient |
1,249 |
1,233 |
$38K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,531 |
1,508 |
$35K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
248 |
116 |
$25K |
| D0330 |
Panoramic radiographic image |
370 |
366 |
$16K |
| D1120 |
Prophylaxis - child |
369 |
359 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
273 |
270 |
$15K |
| D0274 |
Bitewings - four radiographic images |
109 |
109 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
130 |
129 |
$2K |
| D1330 |
|
124 |
124 |
$744.00 |