| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,243 |
1,209 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
1,799 |
1,742 |
$43K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
334 |
203 |
$41K |
| D1120 |
Prophylaxis - child |
844 |
812 |
$27K |
| D0274 |
Bitewings - four radiographic images |
873 |
850 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,234 |
1,194 |
$21K |
| D0330 |
Panoramic radiographic image |
301 |
295 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
177 |
172 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
13 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
144 |
134 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
12 |
$2K |
| D1206 |
Topical application of fluoride varnish |
58 |
58 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$465.00 |