| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
674 |
628 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
752 |
712 |
$20K |
| D1206 |
Topical application of fluoride varnish |
831 |
810 |
$20K |
| D1120 |
Prophylaxis - child |
249 |
247 |
$11K |
| D0274 |
Bitewings - four radiographic images |
400 |
373 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
549 |
496 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
36 |
24 |
$4K |
| D1330 |
|
507 |
497 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
425 |
323 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
37 |
37 |
$2K |
| D0330 |
Panoramic radiographic image |
36 |
36 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
15 |
13 |
$405.60 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$195.00 |