| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
728 |
728 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
865 |
865 |
$24K |
| D0274 |
Bitewings - four radiographic images |
190 |
190 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
33 |
26 |
$3K |
| D0330 |
Panoramic radiographic image |
41 |
41 |
$2K |
| D1120 |
Prophylaxis - child |
53 |
53 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
82 |
82 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
27 |
$769.50 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$250.80 |
| D0220 |
Intraoral - periapical first radiographic image |
16 |
16 |
$199.50 |