| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
407 |
407 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
651 |
651 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
120 |
57 |
$9K |
| D0274 |
Bitewings - four radiographic images |
308 |
306 |
$8K |
| D0330 |
Panoramic radiographic image |
164 |
163 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
91 |
45 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
129 |
129 |
$4K |
| D1120 |
Prophylaxis - child |
58 |
57 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
22 |
14 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
122 |
119 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
75 |
75 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
29 |
29 |
$406.00 |