| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
382 |
379 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
666 |
644 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
423 |
419 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
315 |
313 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
66 |
33 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
454 |
388 |
$6K |
| D0274 |
Bitewings - four radiographic images |
149 |
148 |
$5K |
| D0350 |
|
64 |
62 |
$3K |
| D9110 |
|
42 |
42 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
29 |
29 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
34 |
31 |
$1K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$816.00 |
| D0460 |
|
12 |
12 |
$259.20 |