| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
86 |
85 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
146 |
146 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
148 |
148 |
$3K |
| D1120 |
Prophylaxis - child |
68 |
68 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
13 |
$2K |
| D0330 |
Panoramic radiographic image |
45 |
31 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
55 |
44 |
$1K |
| D0274 |
Bitewings - four radiographic images |
46 |
46 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
46 |
31 |
$794.56 |