| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
477 |
477 |
$14K |
| D1110 |
Prophylaxis - adult |
227 |
227 |
$11K |
| D0274 |
Bitewings - four radiographic images |
165 |
165 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
44 |
29 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
168 |
168 |
$3K |
| D1120 |
Prophylaxis - child |
66 |
66 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
93 |
93 |
$2K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$519.95 |