| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
299 |
293 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
47 |
28 |
$9K |
| D0274 |
Bitewings - four radiographic images |
246 |
240 |
$8K |
| D1120 |
Prophylaxis - child |
190 |
185 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
252 |
245 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
289 |
286 |
$5K |
| D0330 |
Panoramic radiographic image |
69 |
67 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
25 |
17 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
69 |
68 |
$2K |
| D0272 |
Bitewings - two radiographic images |
41 |
40 |
$793.32 |
| D0140 |
Limited oral evaluation - problem focused |
21 |
19 |
$675.60 |