| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
562 |
561 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
602 |
601 |
$11K |
| D0330 |
Panoramic radiographic image |
124 |
124 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
191 |
191 |
$4K |
| D0274 |
Bitewings - four radiographic images |
116 |
116 |
$3K |
| D1120 |
Prophylaxis - child |
79 |
78 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
62 |
62 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
13 |
$848.00 |
| D0220 |
Intraoral - periapical first radiographic image |
77 |
75 |
$494.96 |