| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
765 |
739 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
400 |
168 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
1,026 |
979 |
$19K |
| D1120 |
Prophylaxis - child |
403 |
392 |
$18K |
| D0274 |
Bitewings - four radiographic images |
653 |
626 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
700 |
667 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
575 |
522 |
$5K |
| D0330 |
Panoramic radiographic image |
135 |
130 |
$5K |
| D1206 |
Topical application of fluoride varnish |
291 |
284 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
160 |
151 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
264 |
242 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
23 |
12 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
12 |
$963.88 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
12 |
$311.85 |