| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
532 |
523 |
$34K |
| D0140 |
Limited oral evaluation - problem focused |
433 |
402 |
$20K |
| D3120 |
|
544 |
229 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
116 |
70 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
176 |
167 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
147 |
143 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
241 |
241 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
593 |
494 |
$7K |
| D0274 |
Bitewings - four radiographic images |
143 |
136 |
$3K |
| D0330 |
Panoramic radiographic image |
75 |
67 |
$3K |
| D1206 |
Topical application of fluoride varnish |
75 |
72 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
81 |
73 |
$872.48 |