| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
187 |
187 |
$12K |
| D1206 |
Topical application of fluoride varnish |
446 |
443 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
118 |
118 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
130 |
127 |
$6K |
| D0330 |
Panoramic radiographic image |
131 |
129 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
181 |
181 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
14 |
12 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
33 |
33 |
$2K |
| D0274 |
Bitewings - four radiographic images |
53 |
53 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
57 |
55 |
$622.52 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$508.44 |