| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,291 |
1,291 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
1,671 |
1,671 |
$28K |
| D0274 |
Bitewings - four radiographic images |
1,409 |
1,409 |
$19K |
| D1120 |
Prophylaxis - child |
519 |
519 |
$13K |
| D0330 |
Panoramic radiographic image |
510 |
510 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
1,429 |
1,426 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,157 |
1,157 |
$7K |
| D1206 |
Topical application of fluoride varnish |
416 |
416 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
103 |
68 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
108 |
108 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
86 |
85 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
13 |
$928.00 |