| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
427 |
426 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
653 |
652 |
$15K |
| D1206 |
Topical application of fluoride varnish |
561 |
561 |
$10K |
| D1120 |
Prophylaxis - child |
210 |
210 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
50 |
25 |
$6K |
| D0274 |
Bitewings - four radiographic images |
208 |
208 |
$6K |
| D0330 |
Panoramic radiographic image |
39 |
39 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$463.92 |
| D0220 |
Intraoral - periapical first radiographic image |
26 |
26 |
$326.82 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$251.40 |