| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
240 |
238 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
363 |
359 |
$10K |
| D1206 |
Topical application of fluoride varnish |
443 |
441 |
$9K |
| D0274 |
Bitewings - four radiographic images |
133 |
128 |
$3K |
| D1120 |
Prophylaxis - child |
105 |
103 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
62 |
59 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
12 |
$831.06 |
| D0330 |
Panoramic radiographic image |
29 |
28 |
$734.32 |
| D0220 |
Intraoral - periapical first radiographic image |
64 |
61 |
$667.50 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
105 |
99 |
$615.00 |
| D1330 |
|
81 |
68 |
$0.00 |
| D1310 |
|
21 |
13 |
$0.00 |
| D9985 |
|
32 |
29 |
$0.00 |