| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,179 |
2,179 |
$116K |
| D0120 |
Periodic oral evaluation - established patient |
2,761 |
2,760 |
$76K |
| D0274 |
Bitewings - four radiographic images |
1,132 |
1,132 |
$41K |
| D1120 |
Prophylaxis - child |
392 |
392 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
173 |
109 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
781 |
781 |
$11K |
| D0330 |
Panoramic radiographic image |
183 |
183 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
135 |
86 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
462 |
455 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
69 |
69 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
109 |
108 |
$2K |