| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
561 |
556 |
$10K |
| D1206 |
Topical application of fluoride varnish |
493 |
493 |
$8K |
| D1110 |
Prophylaxis - adult |
213 |
213 |
$8K |
| D1120 |
Prophylaxis - child |
365 |
365 |
$7K |
| D0330 |
Panoramic radiographic image |
119 |
119 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
196 |
196 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
36 |
28 |
$2K |
| D0274 |
Bitewings - four radiographic images |
103 |
103 |
$966.00 |
| D0272 |
Bitewings - two radiographic images |
38 |
38 |
$346.50 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
12 |
$331.94 |