| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,048 |
1,048 |
$61K |
| D0120 |
Periodic oral evaluation - established patient |
930 |
930 |
$27K |
| D1120 |
Prophylaxis - child |
544 |
544 |
$23K |
| D0330 |
Panoramic radiographic image |
287 |
287 |
$20K |
| D0274 |
Bitewings - four radiographic images |
426 |
426 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
750 |
750 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
110 |
73 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
276 |
276 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
143 |
143 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
79 |
58 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
351 |
348 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
59 |
59 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
16 |
16 |
$275.50 |