| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
406 |
399 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
478 |
472 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
202 |
199 |
$12K |
| D0330 |
Panoramic radiographic image |
136 |
133 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
94 |
94 |
$1K |
| D0274 |
Bitewings - four radiographic images |
61 |
61 |
$1K |
| D1120 |
Prophylaxis - child |
60 |
59 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
12 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
56 |
56 |
$939.40 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
13 |
$293.54 |