| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
348 |
348 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
575 |
575 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
554 |
554 |
$9K |
| D1120 |
Prophylaxis - child |
161 |
161 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
48 |
24 |
$5K |
| D0274 |
Bitewings - four radiographic images |
113 |
113 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
55 |
55 |
$2K |
| D0330 |
Panoramic radiographic image |
30 |
30 |
$2K |
| D0272 |
Bitewings - two radiographic images |
34 |
34 |
$643.96 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
12 |
$500.50 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$153.96 |