| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,807 |
2,807 |
$151K |
| D0120 |
Periodic oral evaluation - established patient |
3,184 |
3,183 |
$87K |
| D0330 |
Panoramic radiographic image |
1,048 |
1,048 |
$48K |
| D0274 |
Bitewings - four radiographic images |
802 |
802 |
$28K |
| D0272 |
Bitewings - two radiographic images |
1,194 |
1,194 |
$23K |
| D1120 |
Prophylaxis - child |
480 |
480 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,224 |
1,224 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
576 |
576 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
51 |
37 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
147 |
144 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
109 |
109 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$206.80 |