| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
937 |
901 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,267 |
1,205 |
$30K |
| D0220 |
Intraoral - periapical first radiographic image |
1,145 |
1,055 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
154 |
85 |
$16K |
| D0274 |
Bitewings - four radiographic images |
407 |
389 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
131 |
65 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
789 |
649 |
$9K |
| D1206 |
Topical application of fluoride varnish |
484 |
462 |
$7K |
| D1120 |
Prophylaxis - child |
173 |
159 |
$4K |
| D0330 |
Panoramic radiographic image |
60 |
57 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
45 |
44 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
15 |
14 |
$494.02 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$211.08 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$207.48 |