| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,124 |
2,124 |
$76K |
| D0120 |
Periodic oral evaluation - established patient |
1,863 |
1,863 |
$37K |
| D0330 |
Panoramic radiographic image |
677 |
677 |
$17K |
| D0272 |
Bitewings - two radiographic images |
1,240 |
1,239 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
147 |
90 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
234 |
234 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
68 |
68 |
$711.16 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$354.00 |
| D0220 |
Intraoral - periapical first radiographic image |
25 |
25 |
$265.44 |
| D0230 |
Intraoral - periapical each additional radiographic image |
28 |
28 |
$166.92 |