| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
933 |
907 |
$37K |
| D1120 |
Prophylaxis - child |
1,040 |
999 |
$31K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
555 |
278 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
415 |
223 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
1,210 |
1,170 |
$27K |
| D1206 |
Topical application of fluoride varnish |
1,288 |
1,242 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
567 |
552 |
$14K |
| D0274 |
Bitewings - four radiographic images |
504 |
487 |
$12K |
| D0330 |
Panoramic radiographic image |
293 |
283 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
193 |
189 |
$4K |
| D0272 |
Bitewings - two radiographic images |
210 |
208 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
76 |
71 |
$836.95 |
| D0230 |
Intraoral - periapical each additional radiographic image |
65 |
32 |
$533.85 |