| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,438 |
1,367 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
2,233 |
2,133 |
$37K |
| D1208 |
Topical application of fluoride, excluding varnish |
956 |
909 |
$13K |
| D1120 |
Prophylaxis - child |
649 |
620 |
$12K |
| D0274 |
Bitewings - four radiographic images |
544 |
516 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
190 |
127 |
$9K |
| D0330 |
Panoramic radiographic image |
106 |
101 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
62 |
41 |
$3K |
| D2330 |
|
42 |
25 |
$2K |
| D0272 |
Bitewings - two radiographic images |
114 |
110 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
42 |
38 |
$862.62 |
| D0220 |
Intraoral - periapical first radiographic image |
36 |
27 |
$120.00 |