| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
306 |
306 |
$13K |
| D0330 |
Panoramic radiographic image |
257 |
257 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
320 |
320 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
90 |
48 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
106 |
43 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
48 |
48 |
$537.30 |
| D0220 |
Intraoral - periapical first radiographic image |
30 |
30 |
$323.40 |
| D0120 |
Periodic oral evaluation - established patient |
12 |
12 |
$255.20 |
| D0230 |
Intraoral - periapical each additional radiographic image |
14 |
14 |
$102.80 |