| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,344 |
1,342 |
$56K |
| D0120 |
Periodic oral evaluation - established patient |
1,312 |
1,311 |
$32K |
| D0230 |
Intraoral - periapical each additional radiographic image |
847 |
770 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
125 |
76 |
$7K |
| D0330 |
Panoramic radiographic image |
161 |
161 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
1,222 |
1,179 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
111 |
108 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
143 |
143 |
$3K |
| D1120 |
Prophylaxis - child |
38 |
38 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
51 |
51 |
$1K |
| D0274 |
Bitewings - four radiographic images |
104 |
104 |
$1K |