| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
337 |
335 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
713 |
333 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
702 |
614 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
313 |
311 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
67 |
37 |
$5K |
| D0274 |
Bitewings - four radiographic images |
175 |
173 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
121 |
120 |
$4K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$647.88 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$351.39 |