| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
956 |
870 |
$36K |
| D1206 |
Topical application of fluoride varnish |
1,412 |
1,289 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
993 |
912 |
$21K |
| D1120 |
Prophylaxis - child |
431 |
395 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
323 |
284 |
$8K |
| D0274 |
Bitewings - four radiographic images |
326 |
295 |
$6K |
| D0330 |
Panoramic radiographic image |
155 |
138 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
62 |
38 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
35 |
24 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
31 |
31 |
$2K |
| D0272 |
Bitewings - two radiographic images |
76 |
66 |
$1K |