| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,359 |
1,346 |
$57K |
| D0120 |
Periodic oral evaluation - established patient |
1,417 |
1,406 |
$33K |
| D0274 |
Bitewings - four radiographic images |
172 |
168 |
$4K |
| D1206 |
Topical application of fluoride varnish |
137 |
137 |
$3K |
| D1120 |
Prophylaxis - child |
73 |
73 |
$3K |
| D0330 |
Panoramic radiographic image |
92 |
88 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
93 |
91 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
27 |
25 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
85 |
83 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$806.02 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
15 |
$281.90 |