| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
434 |
373 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
258 |
77 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
196 |
85 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
377 |
325 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
118 |
100 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
334 |
286 |
$6K |
| D0274 |
Bitewings - four radiographic images |
179 |
160 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
455 |
168 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
113 |
96 |
$3K |
| D0330 |
Panoramic radiographic image |
104 |
58 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
278 |
213 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
12 |
$2K |
| D1206 |
Topical application of fluoride varnish |
53 |
41 |
$754.29 |