| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
475 |
475 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
421 |
421 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
82 |
55 |
$8K |
| D0274 |
Bitewings - four radiographic images |
193 |
193 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
134 |
134 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
249 |
249 |
$4K |
| D0330 |
Panoramic radiographic image |
99 |
99 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
238 |
238 |
$4K |
| D1120 |
Prophylaxis - child |
35 |
35 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
16 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
81 |
81 |
$1K |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$306.42 |