| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
588 |
588 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
983 |
983 |
$38K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
295 |
235 |
$29K |
| D0274 |
Bitewings - four radiographic images |
455 |
455 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
491 |
490 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
95 |
69 |
$6K |
| D1120 |
Prophylaxis - child |
106 |
106 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
185 |
185 |
$4K |
| D0272 |
Bitewings - two radiographic images |
95 |
95 |
$3K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$451.00 |
| D1330 |
|
845 |
845 |
$0.00 |