| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
772 |
690 |
$39K |
| D1206 |
Topical application of fluoride varnish |
1,214 |
1,054 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
580 |
541 |
$24K |
| D0180 |
|
595 |
505 |
$23K |
| D1120 |
Prophylaxis - child |
452 |
383 |
$15K |
| D0274 |
Bitewings - four radiographic images |
444 |
352 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
104 |
63 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
345 |
326 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
240 |
196 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
242 |
233 |
$6K |
| D0330 |
Panoramic radiographic image |
109 |
71 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
52 |
52 |
$992.62 |