| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
885 |
885 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
1,191 |
1,191 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
709 |
709 |
$12K |
| D0274 |
Bitewings - four radiographic images |
308 |
308 |
$7K |
| D1120 |
Prophylaxis - child |
132 |
132 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
112 |
112 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
13 |
$2K |
| D1206 |
Topical application of fluoride varnish |
81 |
81 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$499.70 |