| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
625 |
545 |
$47K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
412 |
353 |
$23K |
| D1120 |
Prophylaxis - child |
401 |
351 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
532 |
456 |
$22K |
| D1206 |
Topical application of fluoride varnish |
772 |
683 |
$20K |
| D0274 |
Bitewings - four radiographic images |
360 |
308 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
487 |
444 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
186 |
160 |
$11K |
| D0330 |
Panoramic radiographic image |
79 |
70 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
33 |
24 |
$6K |
| D0272 |
Bitewings - two radiographic images |
128 |
114 |
$5K |
| D1351 |
Sealant - per tooth |
59 |
24 |
$3K |