| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,510 |
1,507 |
$73K |
| D0120 |
Periodic oral evaluation - established patient |
1,703 |
1,701 |
$43K |
| D0220 |
Intraoral - periapical first radiographic image |
506 |
492 |
$5K |
| D0272 |
Bitewings - two radiographic images |
297 |
296 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
315 |
315 |
$4K |
| D0274 |
Bitewings - four radiographic images |
174 |
173 |
$3K |
| D1120 |
Prophylaxis - child |
59 |
59 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
12 |
12 |
$998.60 |
| D1208 |
Topical application of fluoride, excluding varnish |
57 |
57 |
$624.65 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$367.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
61 |
60 |
$313.32 |