| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
646 |
642 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
799 |
798 |
$24K |
| D1206 |
Topical application of fluoride varnish |
407 |
407 |
$13K |
| D0330 |
Panoramic radiographic image |
268 |
266 |
$11K |
| D1120 |
Prophylaxis - child |
231 |
231 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
66 |
48 |
$5K |
| D0274 |
Bitewings - four radiographic images |
381 |
381 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
63 |
62 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
616 |
570 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
96 |
93 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
45 |
45 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
175 |
163 |
$366.00 |
| D0602 |
|
27 |
27 |
$270.00 |
| D0272 |
Bitewings - two radiographic images |
27 |
27 |
$270.00 |