| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
567 |
489 |
$41K |
| D0330 |
Panoramic radiographic image |
349 |
306 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
583 |
509 |
$23K |
| D1206 |
Topical application of fluoride varnish |
770 |
679 |
$19K |
| D0274 |
Bitewings - four radiographic images |
370 |
313 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
247 |
229 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
179 |
157 |
$10K |
| D1351 |
Sealant - per tooth |
211 |
24 |
$8K |
| D1120 |
Prophylaxis - child |
126 |
112 |
$7K |
| D0272 |
Bitewings - two radiographic images |
117 |
107 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
150 |
139 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
13 |
$3K |
| D4910 |
|
15 |
13 |
$1K |