| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
278 |
234 |
$8K |
| D1120 |
Prophylaxis - child |
221 |
194 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
360 |
311 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
256 |
227 |
$5K |
| D0330 |
Panoramic radiographic image |
168 |
146 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
95 |
42 |
$5K |
| D0274 |
Bitewings - four radiographic images |
169 |
150 |
$3K |
| D1206 |
Topical application of fluoride varnish |
248 |
216 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
79 |
69 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
14 |
$983.20 |
| D0220 |
Intraoral - periapical first radiographic image |
217 |
158 |
$856.26 |
| D1208 |
Topical application of fluoride, excluding varnish |
37 |
37 |
$374.40 |
| D0272 |
Bitewings - two radiographic images |
13 |
12 |
$202.02 |
| D0230 |
Intraoral - periapical each additional radiographic image |
32 |
22 |
$86.48 |