| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
377 |
377 |
$18K |
| D0274 |
Bitewings - four radiographic images |
322 |
322 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
201 |
201 |
$8K |
| D0330 |
Panoramic radiographic image |
161 |
161 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
71 |
38 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
387 |
375 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
118 |
116 |
$4K |
| D1206 |
Topical application of fluoride varnish |
180 |
180 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
129 |
129 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
15 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
94 |
87 |
$773.94 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$417.60 |