| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
307 |
248 |
$9K |
| D0274 |
Bitewings - four radiographic images |
239 |
199 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
283 |
229 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
105 |
87 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
29 |
16 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
12 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
23 |
23 |
$391.00 |
| D0330 |
Panoramic radiographic image |
14 |
13 |
$369.00 |
| D1120 |
Prophylaxis - child |
16 |
16 |
$360.00 |
| D0220 |
Intraoral - periapical first radiographic image |
18 |
13 |
$132.00 |