| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
71 |
68 |
$5K |
| D0330 |
Panoramic radiographic image |
43 |
39 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
109 |
104 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
27 |
15 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
82 |
79 |
$3K |
| D1120 |
Prophylaxis - child |
48 |
46 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
34 |
32 |
$2K |
| D0274 |
Bitewings - four radiographic images |
42 |
41 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
48 |
47 |
$495.36 |
| D0230 |
Intraoral - periapical each additional radiographic image |
46 |
20 |
$474.72 |