| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
545 |
504 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
717 |
673 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
84 |
13 |
$4K |
| D1206 |
Topical application of fluoride varnish |
252 |
236 |
$4K |
| D0274 |
Bitewings - four radiographic images |
77 |
69 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
52 |
17 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
34 |
22 |
$979.65 |
| D0140 |
Limited oral evaluation - problem focused |
28 |
17 |
$620.31 |
| D0330 |
Panoramic radiographic image |
18 |
12 |
$433.65 |
| D0220 |
Intraoral - periapical first radiographic image |
17 |
15 |
$163.60 |
| D0230 |
Intraoral - periapical each additional radiographic image |
16 |
13 |
$138.38 |