| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,164 |
906 |
$41K |
| D1206 |
Topical application of fluoride varnish |
1,210 |
1,022 |
$28K |
| D0140 |
Limited oral evaluation - problem focused |
464 |
373 |
$23K |
| D1110 |
Prophylaxis - adult |
278 |
236 |
$20K |
| D1120 |
Prophylaxis - child |
396 |
305 |
$19K |
| D0330 |
Panoramic radiographic image |
187 |
158 |
$15K |
| D0274 |
Bitewings - four radiographic images |
167 |
131 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
28 |
13 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
13 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
157 |
107 |
$3K |
| D4910 |
|
17 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
34 |
24 |
$832.68 |