| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
483 |
482 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
176 |
111 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
357 |
357 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
348 |
348 |
$10K |
| D0274 |
Bitewings - four radiographic images |
332 |
332 |
$9K |
| D1120 |
Prophylaxis - child |
139 |
139 |
$6K |
| D0330 |
Panoramic radiographic image |
154 |
154 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
68 |
68 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
218 |
218 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
87 |
85 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
25 |
25 |
$333.20 |