| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
225 |
212 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
321 |
307 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
67 |
39 |
$4K |
| D1206 |
Topical application of fluoride varnish |
226 |
212 |
$3K |
| D0274 |
Bitewings - four radiographic images |
58 |
56 |
$943.92 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
12 |
$782.85 |
| D1120 |
Prophylaxis - child |
30 |
26 |
$666.54 |
| D0220 |
Intraoral - periapical first radiographic image |
66 |
62 |
$504.60 |
| D0330 |
Panoramic radiographic image |
18 |
15 |
$423.30 |
| D0230 |
Intraoral - periapical each additional radiographic image |
33 |
14 |
$130.52 |
| D0603 |
|
22 |
22 |
$110.00 |
| D0600 |
|
36 |
36 |
$0.00 |
| D1999 |
|
15 |
15 |
$0.00 |