| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
254 |
252 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
373 |
365 |
$6K |
| D0274 |
Bitewings - four radiographic images |
195 |
192 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
108 |
101 |
$3K |
| D1206 |
Topical application of fluoride varnish |
175 |
170 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
263 |
246 |
$2K |
| D0330 |
Panoramic radiographic image |
31 |
31 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
29 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
131 |
118 |
$692.22 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$315.90 |