| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,045 |
1,043 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
1,010 |
1,007 |
$25K |
| D0274 |
Bitewings - four radiographic images |
906 |
904 |
$23K |
| D0330 |
Panoramic radiographic image |
227 |
227 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
219 |
217 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
90 |
90 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
174 |
174 |
$2K |
| D1120 |
Prophylaxis - child |
53 |
53 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
78 |
78 |
$981.00 |