| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
734 |
695 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
1,080 |
1,025 |
$18K |
| D0274 |
Bitewings - four radiographic images |
347 |
330 |
$7K |
| D1206 |
Topical application of fluoride varnish |
420 |
399 |
$6K |
| D1120 |
Prophylaxis - child |
303 |
289 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
119 |
115 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
418 |
189 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
286 |
264 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
17 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
14 |
$877.50 |
| D0330 |
Panoramic radiographic image |
16 |
13 |
$562.80 |
| D0272 |
Bitewings - two radiographic images |
28 |
28 |
$287.00 |