| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
365 |
365 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
329 |
329 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
126 |
120 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
78 |
45 |
$4K |
| D0274 |
Bitewings - four radiographic images |
385 |
385 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
866 |
846 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
688 |
680 |
$3K |
| D0330 |
Panoramic radiographic image |
105 |
105 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
46 |
32 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
79 |
79 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
24 |
24 |
$375.00 |