| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
442 |
442 |
$29K |
| D1206 |
Topical application of fluoride varnish |
773 |
772 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
559 |
559 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
213 |
213 |
$12K |
| D1120 |
Prophylaxis - child |
142 |
142 |
$7K |
| D0274 |
Bitewings - four radiographic images |
183 |
183 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
336 |
331 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
25 |
14 |
$3K |
| D0330 |
Panoramic radiographic image |
61 |
61 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
244 |
243 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
12 |
$614.38 |
| D1330 |
|
61 |
60 |
$374.40 |