| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
676 |
674 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
731 |
730 |
$25K |
| D0274 |
Bitewings - four radiographic images |
754 |
753 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
618 |
609 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
666 |
666 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
408 |
403 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
57 |
40 |
$4K |
| D0330 |
Panoramic radiographic image |
68 |
68 |
$3K |
| D1120 |
Prophylaxis - child |
12 |
12 |
$395.92 |
| D0270 |
|
13 |
13 |
$132.84 |