| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
783 |
751 |
$43K |
| D0140 |
Limited oral evaluation - problem focused |
944 |
879 |
$34K |
| D0330 |
Panoramic radiographic image |
437 |
415 |
$28K |
| D1120 |
Prophylaxis - child |
672 |
584 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
962 |
797 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
584 |
559 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
930 |
819 |
$19K |
| D0274 |
Bitewings - four radiographic images |
313 |
303 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
88 |
68 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
601 |
570 |
$9K |
| D9630 |
|
68 |
56 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
13 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
33 |
28 |
$797.50 |
| D0230 |
Intraoral - periapical each additional radiographic image |
34 |
12 |
$187.00 |