| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
159 |
158 |
$6K |
| D0330 |
Panoramic radiographic image |
101 |
101 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
154 |
154 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
44 |
27 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
75 |
75 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$252.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$204.75 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$65.25 |