| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
408 |
363 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
589 |
499 |
$13K |
| D1120 |
Prophylaxis - child |
299 |
247 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
568 |
472 |
$10K |
| D0330 |
Panoramic radiographic image |
201 |
187 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
260 |
215 |
$8K |
| D0274 |
Bitewings - four radiographic images |
230 |
195 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
526 |
450 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
34 |
24 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
92 |
82 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
149 |
65 |
$979.00 |