| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
596 |
530 |
$18K |
| D1206 |
Topical application of fluoride varnish |
1,136 |
947 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
981 |
821 |
$13K |
| D0274 |
Bitewings - four radiographic images |
408 |
345 |
$7K |
| D4910 |
|
149 |
146 |
$7K |
| D1120 |
Prophylaxis - child |
297 |
216 |
$5K |
| D0330 |
Panoramic radiographic image |
66 |
65 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
70 |
69 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
26 |
26 |
$622.58 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14 |
12 |
$574.09 |
| D0220 |
Intraoral - periapical first radiographic image |
63 |
61 |
$480.81 |
| D0272 |
Bitewings - two radiographic images |
36 |
24 |
$394.14 |