| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
502 |
500 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
571 |
569 |
$11K |
| D0330 |
Panoramic radiographic image |
177 |
174 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
95 |
87 |
$5K |
| D0272 |
Bitewings - two radiographic images |
321 |
317 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
96 |
80 |
$5K |
| D1120 |
Prophylaxis - child |
137 |
137 |
$4K |
| D1206 |
Topical application of fluoride varnish |
225 |
224 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
153 |
150 |
$3K |
| D2330 |
|
46 |
27 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
224 |
221 |
$2K |
| D9110 |
|
44 |
44 |
$1K |
| D0274 |
Bitewings - four radiographic images |
19 |
19 |
$476.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
24 |
24 |
$184.00 |