| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,494 |
1,494 |
$75K |
| D0120 |
Periodic oral evaluation - established patient |
1,694 |
1,694 |
$39K |
| D0272 |
Bitewings - two radiographic images |
1,613 |
1,613 |
$30K |
| D0140 |
Limited oral evaluation - problem focused |
388 |
374 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
890 |
890 |
$14K |
| D0330 |
Panoramic radiographic image |
273 |
273 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
57 |
39 |
$6K |
| D1120 |
Prophylaxis - child |
134 |
134 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
366 |
339 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
39 |
24 |
$3K |