| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
830 |
819 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
743 |
733 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
842 |
823 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
311 |
309 |
$10K |
| D0274 |
Bitewings - four radiographic images |
302 |
300 |
$8K |
| D0330 |
Panoramic radiographic image |
141 |
141 |
$5K |
| D1120 |
Prophylaxis - child |
102 |
102 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
16 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
43 |
43 |
$469.56 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$297.96 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
13 |
12 |
$0.00 |