| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
587 |
586 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
731 |
730 |
$14K |
| D0274 |
Bitewings - four radiographic images |
239 |
239 |
$6K |
| D1120 |
Prophylaxis - child |
182 |
182 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
105 |
68 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
252 |
252 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
39 |
30 |
$2K |
| D0330 |
Panoramic radiographic image |
47 |
46 |
$2K |
| D2330 |
|
32 |
25 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$240.00 |