| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
400 |
399 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
415 |
414 |
$10K |
| D1120 |
Prophylaxis - child |
147 |
147 |
$7K |
| D1206 |
Topical application of fluoride varnish |
197 |
196 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
118 |
106 |
$5K |
| D0274 |
Bitewings - four radiographic images |
384 |
384 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
149 |
149 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
65 |
25 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
609 |
597 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
76 |
76 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
38 |
38 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
406 |
403 |
$1K |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$1K |