| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,836 |
1,611 |
$71K |
| D0120 |
Periodic oral evaluation - established patient |
2,789 |
2,469 |
$51K |
| D0274 |
Bitewings - four radiographic images |
887 |
751 |
$23K |
| D1206 |
Topical application of fluoride varnish |
690 |
594 |
$13K |
| D1120 |
Prophylaxis - child |
458 |
398 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
223 |
197 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
309 |
252 |
$2K |
| D0330 |
Panoramic radiographic image |
30 |
27 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
184 |
164 |
$716.48 |
| D0272 |
Bitewings - two radiographic images |
15 |
12 |
$347.34 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
12 |
$222.00 |