| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
718 |
709 |
$45K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
421 |
415 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
952 |
941 |
$22K |
| D0330 |
Panoramic radiographic image |
438 |
431 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
546 |
544 |
$17K |
| D0274 |
Bitewings - four radiographic images |
576 |
569 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
48 |
28 |
$8K |
| D1120 |
Prophylaxis - child |
72 |
72 |
$3K |
| D1330 |
|
135 |
135 |
$820.80 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$614.38 |
| D0220 |
Intraoral - periapical first radiographic image |
31 |
31 |
$354.60 |