| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
706 |
658 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
896 |
829 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
626 |
584 |
$16K |
| D0274 |
Bitewings - four radiographic images |
327 |
307 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
823 |
753 |
$4K |
| D1110 |
Prophylaxis - adult |
126 |
113 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
91 |
60 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
46 |
38 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
714 |
655 |
$3K |
| D0330 |
Panoramic radiographic image |
81 |
81 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
53 |
49 |
$1K |
| D9110 |
|
12 |
12 |
$605.00 |
| D0272 |
Bitewings - two radiographic images |
59 |
56 |
$517.00 |