| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
295 |
285 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
147 |
70 |
$12K |
| D0330 |
Panoramic radiographic image |
110 |
108 |
$7K |
| D0274 |
Bitewings - four radiographic images |
217 |
213 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
284 |
275 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
142 |
138 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
206 |
200 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
357 |
346 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
324 |
251 |
$4K |
| D2950 |
|
14 |
12 |
$2K |
| D1120 |
Prophylaxis - child |
38 |
38 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
41 |
41 |
$1K |