| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
407 |
363 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
168 |
83 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
492 |
440 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
96 |
42 |
$8K |
| D0330 |
Panoramic radiographic image |
105 |
95 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
231 |
207 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
47 |
42 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
106 |
93 |
$2K |
| D1206 |
Topical application of fluoride varnish |
49 |
45 |
$790.00 |