| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
172 |
161 |
$8K |
| D0330 |
Panoramic radiographic image |
115 |
113 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
155 |
144 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
143 |
134 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
131 |
126 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
162 |
148 |
$3K |
| D0274 |
Bitewings - four radiographic images |
72 |
72 |
$3K |
| D1206 |
Topical application of fluoride varnish |
99 |
96 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
13 |
$2K |
| D0350 |
|
40 |
36 |
$859.09 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$588.36 |