| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,691 |
1,455 |
$43K |
| D0274 |
Bitewings - four radiographic images |
1,445 |
1,257 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,476 |
1,313 |
$28K |
| D1120 |
Prophylaxis - child |
583 |
541 |
$21K |
| D0330 |
Panoramic radiographic image |
832 |
679 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
235 |
121 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
157 |
90 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
401 |
386 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
90 |
55 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
309 |
241 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
716 |
605 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
91 |
72 |
$2K |
| D1206 |
Topical application of fluoride varnish |
18 |
16 |
$452.30 |