| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
407 |
403 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
702 |
696 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
223 |
125 |
$29K |
| D1120 |
Prophylaxis - child |
383 |
380 |
$23K |
| D1206 |
Topical application of fluoride varnish |
765 |
760 |
$22K |
| D0330 |
Panoramic radiographic image |
226 |
225 |
$18K |
| D0274 |
Bitewings - four radiographic images |
311 |
307 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
274 |
264 |
$11K |
| D1330 |
|
403 |
403 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
65 |
44 |
$10K |
| D9986 |
|
278 |
253 |
$5K |
| D2394 |
|
14 |
12 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
60 |
60 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
144 |
143 |
$2K |