| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
157 |
149 |
$4K |
| D1206 |
Topical application of fluoride varnish |
293 |
272 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
212 |
192 |
$3K |
| D0274 |
Bitewings - four radiographic images |
202 |
172 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
395 |
355 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
128 |
121 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
51 |
39 |
$2K |
| D1120 |
Prophylaxis - child |
75 |
75 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
100 |
88 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
316 |
220 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
28 |
13 |
$913.70 |
| D0330 |
Panoramic radiographic image |
26 |
23 |
$654.75 |