| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
433 |
433 |
$22K |
| D0330 |
Panoramic radiographic image |
286 |
286 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
324 |
322 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
553 |
539 |
$7K |
| D0272 |
Bitewings - two radiographic images |
298 |
298 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
209 |
209 |
$5K |
| D0274 |
Bitewings - four radiographic images |
177 |
177 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
87 |
87 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$2K |
| D1206 |
Topical application of fluoride varnish |
78 |
78 |
$1K |