| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
346 |
344 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
574 |
572 |
$15K |
| D0274 |
Bitewings - four radiographic images |
142 |
141 |
$4K |
| D0330 |
Panoramic radiographic image |
57 |
57 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
13 |
$1K |
| D1120 |
Prophylaxis - child |
27 |
27 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
67 |
67 |
$933.44 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
17 |
17 |
$451.00 |
| D0220 |
Intraoral - periapical first radiographic image |
24 |
24 |
$287.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$154.00 |