| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,128 |
2,128 |
$103K |
| D0120 |
Periodic oral evaluation - established patient |
1,931 |
1,931 |
$43K |
| D0274 |
Bitewings - four radiographic images |
1,335 |
1,335 |
$36K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,491 |
1,491 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
130 |
88 |
$11K |
| D0330 |
Panoramic radiographic image |
232 |
232 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
239 |
239 |
$9K |
| D0272 |
Bitewings - two radiographic images |
401 |
401 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
543 |
539 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
66 |
65 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
122 |
51 |
$751.33 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$452.40 |