| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,059 |
1,057 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
1,107 |
1,105 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
182 |
82 |
$14K |
| D0274 |
Bitewings - four radiographic images |
953 |
951 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,273 |
1,261 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
659 |
657 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
511 |
506 |
$4K |
| D0330 |
Panoramic radiographic image |
129 |
129 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
71 |
71 |
$2K |
| D1120 |
Prophylaxis - child |
13 |
13 |
$559.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
30 |
30 |
$408.00 |