| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
345 |
344 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
416 |
414 |
$8K |
| D0272 |
Bitewings - two radiographic images |
254 |
254 |
$4K |
| D0330 |
Panoramic radiographic image |
99 |
99 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
110 |
110 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
79 |
79 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
138 |
138 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
14 |
$1K |
| D1120 |
Prophylaxis - child |
31 |
31 |
$930.00 |