| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
504 |
504 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
648 |
648 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
53 |
41 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
129 |
129 |
$2K |
| D0274 |
Bitewings - four radiographic images |
67 |
67 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
33 |
25 |
$2K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$333.00 |
| D0220 |
Intraoral - periapical first radiographic image |
24 |
24 |
$173.00 |