| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
628 |
628 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
408 |
408 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
209 |
209 |
$8K |
| D0274 |
Bitewings - four radiographic images |
221 |
221 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
63 |
58 |
$6K |
| D1206 |
Topical application of fluoride varnish |
306 |
306 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
69 |
69 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
151 |
151 |
$2K |
| D0330 |
Panoramic radiographic image |
36 |
36 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
50 |
50 |
$545.31 |
| D1208 |
Topical application of fluoride, excluding varnish |
17 |
17 |
$275.40 |