| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
704 |
704 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
794 |
793 |
$18K |
| D1120 |
Prophylaxis - child |
321 |
321 |
$9K |
| D0330 |
Panoramic radiographic image |
375 |
375 |
$8K |
| D1206 |
Topical application of fluoride varnish |
389 |
389 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
282 |
282 |
$5K |
| D0272 |
Bitewings - two radiographic images |
661 |
660 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
134 |
105 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
144 |
100 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
56 |
56 |
$888.00 |
| D0601 |
|
43 |
43 |
$430.00 |
| D0274 |
Bitewings - four radiographic images |
69 |
69 |
$297.00 |
| D0603 |
|
26 |
26 |
$260.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$98.00 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$70.00 |