| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,826 |
1,806 |
$94K |
| D0120 |
Periodic oral evaluation - established patient |
2,355 |
2,345 |
$51K |
| D0274 |
Bitewings - four radiographic images |
1,175 |
1,161 |
$34K |
| D1206 |
Topical application of fluoride varnish |
1,594 |
1,589 |
$34K |
| D1120 |
Prophylaxis - child |
811 |
809 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
1,044 |
913 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
458 |
370 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
537 |
430 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
40 |
24 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
117 |
111 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
32 |
16 |
$2K |
| D0330 |
Panoramic radiographic image |
35 |
35 |
$2K |