| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,697 |
1,667 |
$113K |
| D0120 |
Periodic oral evaluation - established patient |
1,330 |
1,312 |
$41K |
| D0274 |
Bitewings - four radiographic images |
1,014 |
990 |
$38K |
| D0140 |
Limited oral evaluation - problem focused |
836 |
781 |
$36K |
| D2750 |
|
48 |
41 |
$24K |
| D0330 |
Panoramic radiographic image |
335 |
329 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
317 |
314 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
700 |
645 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
72 |
40 |
$7K |
| D1120 |
Prophylaxis - child |
24 |
24 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
26 |
26 |
$650.00 |