| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,070 |
1,070 |
$52K |
| D0274 |
Bitewings - four radiographic images |
1,294 |
1,294 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,235 |
1,235 |
$27K |
| D1206 |
Topical application of fluoride varnish |
954 |
954 |
$15K |
| D0330 |
Panoramic radiographic image |
277 |
277 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
486 |
483 |
$6K |
| D1120 |
Prophylaxis - child |
121 |
121 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
83 |
81 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
227 |
227 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
52 |
52 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
14 |
$2K |