| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
228 |
220 |
$10K |
| D1110 |
Prophylaxis - adult |
141 |
138 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
252 |
247 |
$5K |
| D0330 |
Panoramic radiographic image |
93 |
92 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
44 |
34 |
$3K |
| D0274 |
Bitewings - four radiographic images |
109 |
109 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
105 |
103 |
$2K |
| D1206 |
Topical application of fluoride varnish |
191 |
187 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
47 |
34 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
103 |
102 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
13 |
$1K |
| D0272 |
Bitewings - two radiographic images |
58 |
56 |
$860.86 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
14 |
$452.10 |
| D0220 |
Intraoral - periapical first radiographic image |
86 |
78 |
$424.06 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
12 |
$12.42 |