| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
280 |
276 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
503 |
494 |
$9K |
| D1120 |
Prophylaxis - child |
167 |
167 |
$8K |
| D0274 |
Bitewings - four radiographic images |
203 |
202 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
82 |
47 |
$5K |
| D1206 |
Topical application of fluoride varnish |
298 |
295 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
280 |
266 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
41 |
40 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
205 |
142 |
$1K |
| D0330 |
Panoramic radiographic image |
33 |
33 |
$1K |