| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
190 |
177 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
261 |
245 |
$6K |
| D1206 |
Topical application of fluoride varnish |
293 |
274 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
439 |
152 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
298 |
255 |
$3K |
| D0274 |
Bitewings - four radiographic images |
132 |
121 |
$3K |
| D1120 |
Prophylaxis - child |
84 |
77 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
29 |
14 |
$1K |
| D0330 |
Panoramic radiographic image |
40 |
37 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
48 |
44 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
23 |
22 |
$726.64 |