| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
640 |
622 |
$8K |
| D1206 |
Topical application of fluoride varnish |
632 |
626 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
219 |
219 |
$823.21 |
| D0145 |
Oral evaluation for a patient under three years of age |
79 |
79 |
$329.98 |
| D0274 |
Bitewings - four radiographic images |
44 |
44 |
$238.65 |
| D1120 |
Prophylaxis - child |
113 |
113 |
$226.73 |
| D0220 |
Intraoral - periapical first radiographic image |
55 |
54 |
$99.29 |
| D0230 |
Intraoral - periapical each additional radiographic image |
18 |
12 |
$91.11 |
| D1330 |
|
61 |
61 |
$54.02 |
| D4355 |
|
34 |
32 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
42 |
30 |
$0.00 |