| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
652 |
652 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
528 |
528 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
160 |
110 |
$13K |
| D0274 |
Bitewings - four radiographic images |
380 |
379 |
$10K |
| D0330 |
Panoramic radiographic image |
126 |
126 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
68 |
68 |
$2K |
| D1120 |
Prophylaxis - child |
14 |
14 |
$571.90 |
| D0220 |
Intraoral - periapical first radiographic image |
43 |
43 |
$441.45 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$186.20 |