| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
807 |
807 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
1,121 |
1,121 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
40 |
26 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
95 |
94 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
205 |
205 |
$3K |
| D0272 |
Bitewings - two radiographic images |
127 |
127 |
$2K |
| D0330 |
Panoramic radiographic image |
39 |
39 |
$2K |
| D1120 |
Prophylaxis - child |
39 |
39 |
$1K |
| D0274 |
Bitewings - four radiographic images |
41 |
41 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
71 |
66 |
$837.34 |
| D1206 |
Topical application of fluoride varnish |
16 |
16 |
$259.20 |