| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,378 |
1,357 |
$46K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
445 |
265 |
$38K |
| D0330 |
Panoramic radiographic image |
398 |
392 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
240 |
134 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
382 |
377 |
$11K |
| D0274 |
Bitewings - four radiographic images |
541 |
538 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
847 |
834 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
15 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
441 |
395 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
27 |
26 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
247 |
198 |
$671.85 |
| D1208 |
Topical application of fluoride, excluding varnish |
15 |
15 |
$207.90 |