| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,060 |
1,039 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
1,116 |
1,092 |
$26K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,249 |
1,224 |
$25K |
| D0274 |
Bitewings - four radiographic images |
724 |
708 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
98 |
66 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
88 |
65 |
$5K |
| D0330 |
Panoramic radiographic image |
117 |
113 |
$4K |
| D1120 |
Prophylaxis - child |
52 |
52 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
56 |
56 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$244.00 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$177.52 |