| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,250 |
1,211 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
1,961 |
1,900 |
$33K |
| D0274 |
Bitewings - four radiographic images |
812 |
775 |
$18K |
| D1120 |
Prophylaxis - child |
612 |
585 |
$17K |
| D1206 |
Topical application of fluoride varnish |
842 |
805 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
98 |
64 |
$7K |
| D4910 |
|
61 |
54 |
$3K |
| D0272 |
Bitewings - two radiographic images |
59 |
57 |
$956.44 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14 |
12 |
$821.34 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
28 |
27 |
$637.92 |
| D0220 |
Intraoral - periapical first radiographic image |
58 |
54 |
$577.80 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$408.60 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
12 |
$281.50 |