| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
287 |
287 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
373 |
373 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
260 |
260 |
$7K |
| D1110 |
Prophylaxis - adult |
139 |
139 |
$7K |
| D0274 |
Bitewings - four radiographic images |
225 |
225 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
163 |
163 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
579 |
571 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
153 |
149 |
$3K |
| D0330 |
Panoramic radiographic image |
106 |
106 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
507 |
498 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
14 |
14 |
$852.30 |