| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
368 |
368 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
557 |
539 |
$16K |
| D1206 |
Topical application of fluoride varnish |
527 |
507 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
134 |
134 |
$8K |
| D1120 |
Prophylaxis - child |
75 |
71 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
12 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
13 |
$2K |
| D0330 |
Panoramic radiographic image |
40 |
40 |
$2K |
| D0274 |
Bitewings - four radiographic images |
64 |
64 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
26 |
26 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$141.84 |