| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,101 |
2,101 |
$74K |
| D0330 |
Panoramic radiographic image |
1,058 |
1,058 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,203 |
1,203 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
1,153 |
1,153 |
$23K |
| D1120 |
Prophylaxis - child |
260 |
260 |
$8K |
| D0274 |
Bitewings - four radiographic images |
407 |
407 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
292 |
292 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
46 |
26 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
41 |
41 |
$370.04 |
| D0272 |
Bitewings - two radiographic images |
31 |
31 |
$332.98 |
| D0140 |
Limited oral evaluation - problem focused |
24 |
24 |
$227.96 |