| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
225 |
224 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
305 |
303 |
$8K |
| D1352 |
|
125 |
13 |
$8K |
| D1110 |
Prophylaxis - adult |
140 |
138 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
295 |
294 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
103 |
103 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
88 |
86 |
$4K |
| D0274 |
Bitewings - four radiographic images |
97 |
97 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
27 |
12 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
12 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
93 |
91 |
$2K |
| D0330 |
Panoramic radiographic image |
20 |
20 |
$1K |