| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
570 |
558 |
$18K |
| D1110 |
Prophylaxis - adult |
566 |
566 |
$17K |
| D0330 |
Panoramic radiographic image |
447 |
447 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
430 |
429 |
$9K |
| D1206 |
Topical application of fluoride varnish |
415 |
415 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
250 |
249 |
$5K |
| D0274 |
Bitewings - four radiographic images |
428 |
427 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
543 |
509 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
25 |
13 |
$1K |
| D1120 |
Prophylaxis - child |
13 |
13 |
$422.50 |
| D0230 |
Intraoral - periapical each additional radiographic image |
149 |
148 |
$414.00 |