| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,042 |
1,040 |
$56K |
| D0120 |
Periodic oral evaluation - established patient |
993 |
992 |
$24K |
| D1206 |
Topical application of fluoride varnish |
319 |
319 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,088 |
1,071 |
$8K |
| D0274 |
Bitewings - four radiographic images |
232 |
232 |
$8K |
| D0330 |
Panoramic radiographic image |
120 |
120 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
114 |
114 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
621 |
610 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
12 |
$1K |
| D1120 |
Prophylaxis - child |
15 |
15 |
$825.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$540.00 |