| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
309 |
296 |
$12K |
| D1120 |
Prophylaxis - child |
317 |
312 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
392 |
381 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
262 |
255 |
$7K |
| D0330 |
Panoramic radiographic image |
201 |
193 |
$6K |
| D0274 |
Bitewings - four radiographic images |
248 |
240 |
$5K |
| D1206 |
Topical application of fluoride varnish |
271 |
266 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
71 |
45 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
180 |
172 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
49 |
30 |
$3K |
| D0272 |
Bitewings - two radiographic images |
118 |
115 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
94 |
90 |
$977.89 |
| D0230 |
Intraoral - periapical each additional radiographic image |
50 |
31 |
$394.06 |