| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
507 |
506 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
414 |
414 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
93 |
58 |
$6K |
| D0272 |
Bitewings - two radiographic images |
214 |
213 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
126 |
124 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
45 |
45 |
$842.40 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
27 |
$670.00 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$481.00 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$360.00 |