| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,156 |
1,154 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
1,270 |
1,268 |
$28K |
| D1120 |
Prophylaxis - child |
473 |
473 |
$16K |
| D0272 |
Bitewings - two radiographic images |
904 |
901 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
696 |
696 |
$15K |
| D1330 |
|
1,135 |
1,132 |
$15K |
| D0330 |
Panoramic radiographic image |
354 |
353 |
$15K |
| D1310 |
|
1,135 |
1,132 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
631 |
629 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
36 |
24 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
247 |
246 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
12 |
$805.00 |