| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
727 |
727 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
736 |
735 |
$17K |
| D0274 |
Bitewings - four radiographic images |
378 |
378 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
110 |
110 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
189 |
185 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
158 |
156 |
$2K |
| D1120 |
Prophylaxis - child |
44 |
44 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
121 |
120 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
53 |
53 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
81 |
81 |
$978.95 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
13 |
$841.25 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$404.25 |