| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,452 |
1,410 |
$88K |
| D0120 |
Periodic oral evaluation - established patient |
2,791 |
2,738 |
$83K |
| D1120 |
Prophylaxis - child |
1,687 |
1,656 |
$73K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,858 |
1,819 |
$38K |
| D0330 |
Panoramic radiographic image |
379 |
345 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
255 |
231 |
$13K |
| D0274 |
Bitewings - four radiographic images |
334 |
328 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
188 |
172 |
$8K |
| D1206 |
Topical application of fluoride varnish |
256 |
252 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
55 |
24 |
$5K |
| D1330 |
|
322 |
321 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
190 |
162 |
$2K |