| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
848 |
817 |
$49K |
| D1206 |
Topical application of fluoride varnish |
1,723 |
1,672 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
1,097 |
1,064 |
$32K |
| D1120 |
Prophylaxis - child |
581 |
569 |
$26K |
| D0330 |
Panoramic radiographic image |
286 |
270 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
228 |
218 |
$11K |
| D0274 |
Bitewings - four radiographic images |
499 |
472 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
12 |
$3K |
| D1330 |
|
388 |
366 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$604.80 |