| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,599 |
1,599 |
$78K |
| D0274 |
Bitewings - four radiographic images |
1,187 |
1,187 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
1,211 |
1,211 |
$26K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,027 |
1,027 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
153 |
105 |
$15K |
| D0330 |
Panoramic radiographic image |
319 |
319 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
316 |
316 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
122 |
82 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
82 |
80 |
$3K |
| D0272 |
Bitewings - two radiographic images |
116 |
116 |
$2K |
| D1120 |
Prophylaxis - child |
13 |
13 |
$452.40 |
| D0220 |
Intraoral - periapical first radiographic image |
26 |
26 |
$320.75 |