| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
684 |
683 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
1,176 |
1,171 |
$29K |
| D1120 |
Prophylaxis - child |
285 |
284 |
$15K |
| D0274 |
Bitewings - four radiographic images |
457 |
454 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
878 |
867 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
644 |
641 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
34 |
24 |
$3K |
| D0330 |
Panoramic radiographic image |
66 |
66 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
26 |
26 |
$1K |
| D1206 |
Topical application of fluoride varnish |
28 |
28 |
$868.75 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$240.00 |