| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
763 |
763 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
838 |
838 |
$21K |
| D0274 |
Bitewings - four radiographic images |
591 |
591 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
184 |
100 |
$14K |
| D0330 |
Panoramic radiographic image |
273 |
273 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
69 |
69 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
12 |
$2K |
| D1120 |
Prophylaxis - child |
41 |
41 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
142 |
141 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
56 |
56 |
$752.80 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$390.00 |
| D0140 |
Limited oral evaluation - problem focused |
26 |
26 |
$349.27 |