| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
552 |
528 |
$32K |
| D1206 |
Topical application of fluoride varnish |
833 |
788 |
$31K |
| D1110 |
Prophylaxis - adult |
398 |
374 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
606 |
576 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
337 |
312 |
$24K |
| D0274 |
Bitewings - four radiographic images |
468 |
434 |
$23K |
| D0272 |
Bitewings - two radiographic images |
297 |
285 |
$11K |
| D0330 |
Panoramic radiographic image |
96 |
92 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
60 |
30 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
426 |
243 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
482 |
463 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
28 |
20 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
40 |
36 |
$2K |