| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,182 |
1,182 |
$69K |
| D0120 |
Periodic oral evaluation - established patient |
1,282 |
1,282 |
$37K |
| D0274 |
Bitewings - four radiographic images |
322 |
322 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
546 |
536 |
$8K |
| D1120 |
Prophylaxis - child |
80 |
80 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
37 |
25 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
207 |
207 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
278 |
265 |
$2K |
| D0330 |
Panoramic radiographic image |
29 |
29 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
15 |
15 |
$430.20 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$196.00 |