| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,144 |
3,109 |
$128K |
| D0274 |
Bitewings - four radiographic images |
2,022 |
2,008 |
$58K |
| D0120 |
Periodic oral evaluation - established patient |
2,455 |
2,436 |
$55K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
236 |
124 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
689 |
679 |
$26K |
| D0330 |
Panoramic radiographic image |
457 |
449 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
1,806 |
1,770 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
764 |
758 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
221 |
218 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
86 |
85 |
$1K |
| D1206 |
Topical application of fluoride varnish |
26 |
26 |
$477.84 |