| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,287 |
1,287 |
$64K |
| D0330 |
Panoramic radiographic image |
772 |
772 |
$38K |
| D0140 |
Limited oral evaluation - problem focused |
561 |
560 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
834 |
834 |
$19K |
| D0274 |
Bitewings - four radiographic images |
666 |
666 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
458 |
458 |
$18K |
| D1206 |
Topical application of fluoride varnish |
764 |
764 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
51 |
24 |
$4K |
| D1120 |
Prophylaxis - child |
63 |
63 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$153.96 |