| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,028 |
952 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,879 |
1,749 |
$33K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,333 |
1,242 |
$18K |
| D1120 |
Prophylaxis - child |
554 |
523 |
$14K |
| D0330 |
Panoramic radiographic image |
165 |
153 |
$7K |
| D0274 |
Bitewings - four radiographic images |
219 |
204 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
47 |
26 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
55 |
53 |
$1K |
| D0272 |
Bitewings - two radiographic images |
70 |
67 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
26 |
26 |
$267.35 |