| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,260 |
1,260 |
$64K |
| D0120 |
Periodic oral evaluation - established patient |
2,148 |
2,148 |
$50K |
| D1120 |
Prophylaxis - child |
1,216 |
1,216 |
$43K |
| D1206 |
Topical application of fluoride varnish |
2,486 |
2,486 |
$41K |
| D0272 |
Bitewings - two radiographic images |
1,649 |
1,649 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
248 |
248 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
61 |
42 |
$8K |
| D0330 |
Panoramic radiographic image |
125 |
125 |
$6K |
| D0274 |
Bitewings - four radiographic images |
204 |
204 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
263 |
263 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
240 |
234 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
13 |
$2K |