| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
335 |
335 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
290 |
290 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
252 |
252 |
$10K |
| D0274 |
Bitewings - four radiographic images |
355 |
355 |
$9K |
| D0330 |
Panoramic radiographic image |
185 |
185 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
81 |
63 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
231 |
231 |
$5K |
| D1206 |
Topical application of fluoride varnish |
197 |
197 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
226 |
226 |
$3K |
| D0272 |
Bitewings - two radiographic images |
39 |
39 |
$673.32 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$455.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$226.80 |