| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
478 |
478 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
587 |
586 |
$15K |
| D0274 |
Bitewings - four radiographic images |
293 |
293 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
204 |
197 |
$4K |
| D1120 |
Prophylaxis - child |
40 |
40 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
67 |
65 |
$740.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
44 |
43 |
$637.00 |