| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
312 |
309 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
370 |
368 |
$11K |
| D1120 |
Prophylaxis - child |
179 |
178 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
330 |
327 |
$8K |
| D1206 |
Topical application of fluoride varnish |
314 |
312 |
$5K |
| D0274 |
Bitewings - four radiographic images |
113 |
111 |
$3K |
| D0330 |
Panoramic radiographic image |
43 |
43 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
37 |
24 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
73 |
72 |
$981.15 |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$908.72 |
| D0220 |
Intraoral - periapical first radiographic image |
97 |
93 |
$742.00 |
| D0140 |
Limited oral evaluation - problem focused |
21 |
17 |
$491.70 |
| D1321 |
|
17 |
17 |
$241.50 |