| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
735 |
735 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
926 |
926 |
$20K |
| D1206 |
Topical application of fluoride varnish |
1,061 |
1,061 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,293 |
1,182 |
$15K |
| D1120 |
Prophylaxis - child |
415 |
415 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
269 |
269 |
$10K |
| D0274 |
Bitewings - four radiographic images |
400 |
400 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
809 |
575 |
$7K |
| D0330 |
Panoramic radiographic image |
112 |
112 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
48 |
28 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
39 |
25 |
$4K |
| D0272 |
Bitewings - two radiographic images |
25 |
25 |
$454.56 |