| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
225 |
215 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
319 |
307 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
159 |
59 |
$9K |
| D1120 |
Prophylaxis - child |
242 |
236 |
$7K |
| D1206 |
Topical application of fluoride varnish |
262 |
260 |
$5K |
| D0330 |
Panoramic radiographic image |
198 |
191 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
176 |
173 |
$4K |
| D0274 |
Bitewings - four radiographic images |
180 |
173 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
107 |
101 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
13 |
$1K |
| D0272 |
Bitewings - two radiographic images |
88 |
87 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$127.30 |