| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,940 |
1,940 |
$90K |
| D0120 |
Periodic oral evaluation - established patient |
1,626 |
1,626 |
$35K |
| D0274 |
Bitewings - four radiographic images |
1,270 |
1,270 |
$33K |
| D0220 |
Intraoral - periapical first radiographic image |
2,040 |
2,004 |
$24K |
| D0140 |
Limited oral evaluation - problem focused |
452 |
452 |
$15K |
| D1206 |
Topical application of fluoride varnish |
852 |
852 |
$13K |
| D0330 |
Panoramic radiographic image |
141 |
141 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
427 |
296 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
71 |
71 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$227.28 |