| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
730 |
728 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
954 |
952 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
120 |
105 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
242 |
242 |
$5K |
| D0274 |
Bitewings - four radiographic images |
132 |
132 |
$4K |
| D0330 |
Panoramic radiographic image |
63 |
63 |
$2K |
| D1120 |
Prophylaxis - child |
67 |
67 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
12 |
$850.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
27 |
$520.00 |
| D1310 |
|
39 |
39 |
$382.84 |
| D1330 |
|
40 |
40 |
$200.00 |