| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,922 |
1,922 |
$95K |
| D0120 |
Periodic oral evaluation - established patient |
2,243 |
2,243 |
$50K |
| D0274 |
Bitewings - four radiographic images |
1,245 |
1,245 |
$33K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,681 |
1,681 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
101 |
56 |
$10K |
| D1120 |
Prophylaxis - child |
156 |
156 |
$5K |
| D0330 |
Panoramic radiographic image |
68 |
68 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
78 |
78 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
26 |
26 |
$997.60 |
| D0220 |
Intraoral - periapical first radiographic image |
38 |
38 |
$484.14 |