| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
255 |
255 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
81 |
25 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
298 |
298 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
303 |
303 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
32 |
12 |
$3K |
| D1110 |
Prophylaxis - adult |
55 |
54 |
$3K |
| D0330 |
Panoramic radiographic image |
15 |
15 |
$953.60 |
| D0274 |
Bitewings - four radiographic images |
24 |
24 |
$818.82 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
16 |
$648.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$434.00 |