| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
532 |
531 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
563 |
563 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
133 |
58 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
600 |
581 |
$3K |
| D0274 |
Bitewings - four radiographic images |
167 |
166 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
371 |
367 |
$1K |
| D1120 |
Prophylaxis - child |
41 |
41 |
$820.00 |
| D0140 |
Limited oral evaluation - problem focused |
56 |
56 |
$672.00 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$440.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
15 |
15 |
$300.00 |
| D1206 |
Topical application of fluoride varnish |
16 |
16 |
$120.00 |