| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
462 |
458 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
435 |
426 |
$12K |
| D0274 |
Bitewings - four radiographic images |
204 |
197 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
338 |
322 |
$5K |
| D1120 |
Prophylaxis - child |
119 |
119 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
526 |
210 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
99 |
97 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
121 |
121 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
27 |
16 |
$2K |
| D1206 |
Topical application of fluoride varnish |
40 |
40 |
$975.00 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$542.92 |