| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,345 |
1,334 |
$63K |
| D0120 |
Periodic oral evaluation - established patient |
1,335 |
1,325 |
$31K |
| D0330 |
Panoramic radiographic image |
411 |
402 |
$24K |
| D0274 |
Bitewings - four radiographic images |
768 |
757 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
225 |
219 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
192 |
188 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
60 |
46 |
$7K |
| D1206 |
Topical application of fluoride varnish |
371 |
371 |
$7K |
| D1120 |
Prophylaxis - child |
125 |
125 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
15 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
164 |
163 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
32 |
25 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
103 |
100 |
$2K |
| D0272 |
Bitewings - two radiographic images |
46 |
46 |
$1K |