| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
437 |
376 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
493 |
443 |
$10K |
| D1206 |
Topical application of fluoride varnish |
643 |
588 |
$10K |
| D0274 |
Bitewings - four radiographic images |
360 |
331 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
134 |
39 |
$8K |
| D1120 |
Prophylaxis - child |
143 |
136 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
115 |
102 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
229 |
197 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
107 |
84 |
$971.75 |
| D0330 |
Panoramic radiographic image |
16 |
13 |
$548.34 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$189.40 |