| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D5214 |
|
37 |
36 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
350 |
318 |
$10K |
| D1110 |
Prophylaxis - adult |
142 |
130 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
128 |
118 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
224 |
203 |
$5K |
| D0274 |
Bitewings - four radiographic images |
116 |
109 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
55 |
52 |
$3K |
| D4355 |
|
15 |
15 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
92 |
79 |
$1K |
| D1120 |
Prophylaxis - child |
27 |
25 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$840.00 |
| D0272 |
Bitewings - two radiographic images |
14 |
12 |
$392.00 |