| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
538 |
537 |
$26K |
| D0274 |
Bitewings - four radiographic images |
580 |
579 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
550 |
550 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
798 |
781 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
693 |
691 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
63 |
61 |
$4K |
| D1120 |
Prophylaxis - child |
124 |
124 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
150 |
149 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
195 |
195 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
146 |
144 |
$1K |
| D0330 |
Panoramic radiographic image |
34 |
34 |
$674.00 |