| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
855 |
821 |
$42K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
282 |
175 |
$37K |
| D1206 |
Topical application of fluoride varnish |
1,011 |
962 |
$21K |
| D0274 |
Bitewings - four radiographic images |
485 |
457 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
537 |
511 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
369 |
348 |
$13K |
| D1320 |
|
305 |
291 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
246 |
211 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
113 |
113 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
101 |
70 |
$7K |
| D0330 |
Panoramic radiographic image |
141 |
132 |
$7K |
| D1120 |
Prophylaxis - child |
189 |
177 |
$7K |
| D4910 |
|
46 |
45 |
$3K |
| D2950 |
|
17 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
57 |
56 |
$959.39 |