| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
960 |
746 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
1,114 |
859 |
$20K |
| D0274 |
Bitewings - four radiographic images |
617 |
509 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,270 |
1,008 |
$14K |
| D1206 |
Topical application of fluoride varnish |
783 |
597 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
946 |
694 |
$8K |
| D0330 |
Panoramic radiographic image |
191 |
171 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
180 |
151 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
154 |
135 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
47 |
21 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$2K |
| D1120 |
Prophylaxis - child |
36 |
29 |
$796.88 |