| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
223 |
223 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
204 |
204 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
74 |
36 |
$7K |
| D0330 |
Panoramic radiographic image |
131 |
131 |
$7K |
| D0274 |
Bitewings - four radiographic images |
175 |
175 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
235 |
235 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
63 |
63 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
29 |
27 |
$328.64 |