| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
420 |
419 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
99 |
45 |
$10K |
| D0274 |
Bitewings - four radiographic images |
371 |
367 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
539 |
538 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
576 |
529 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
203 |
200 |
$4K |
| D0330 |
Panoramic radiographic image |
57 |
57 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
130 |
130 |
$3K |
| D1206 |
Topical application of fluoride varnish |
138 |
138 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
86 |
70 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
40 |
40 |
$831.60 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$402.24 |