| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
615 |
615 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
666 |
666 |
$12K |
| D1120 |
Prophylaxis - child |
281 |
281 |
$8K |
| D0272 |
Bitewings - two radiographic images |
751 |
751 |
$6K |
| D0330 |
Panoramic radiographic image |
294 |
294 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
264 |
264 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
585 |
578 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
81 |
53 |
$3K |
| D1206 |
Topical application of fluoride varnish |
204 |
204 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
513 |
509 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
95 |
94 |
$973.97 |
| D1208 |
Topical application of fluoride, excluding varnish |
199 |
199 |
$886.02 |
| D0274 |
Bitewings - four radiographic images |
57 |
57 |
$553.77 |