| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
419 |
419 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
683 |
679 |
$19K |
| D0274 |
Bitewings - four radiographic images |
349 |
349 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
112 |
55 |
$10K |
| D1120 |
Prophylaxis - child |
126 |
126 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
364 |
364 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
12 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
16 |
16 |
$963.50 |
| D0220 |
Intraoral - periapical first radiographic image |
58 |
54 |
$693.50 |
| D0230 |
Intraoral - periapical each additional radiographic image |
43 |
43 |
$555.20 |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$347.20 |