| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,104 |
1,104 |
$40K |
| D0330 |
Panoramic radiographic image |
513 |
513 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
522 |
522 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
671 |
669 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
495 |
495 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
819 |
814 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
344 |
343 |
$4K |
| D0274 |
Bitewings - four radiographic images |
184 |
184 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
31 |
17 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
56 |
56 |
$570.57 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$144.10 |