| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
332 |
328 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
520 |
514 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
85 |
24 |
$8K |
| D0330 |
Panoramic radiographic image |
68 |
68 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
136 |
130 |
$3K |
| D0274 |
Bitewings - four radiographic images |
67 |
67 |
$2K |
| D1120 |
Prophylaxis - child |
28 |
26 |
$938.56 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$0.00 |