| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
451 |
451 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
304 |
304 |
$12K |
| D0330 |
Panoramic radiographic image |
113 |
113 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
208 |
208 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
61 |
13 |
$5K |
| D0272 |
Bitewings - two radiographic images |
75 |
75 |
$1K |
| D9992 |
|
46 |
46 |
$1K |
| D0274 |
Bitewings - four radiographic images |
41 |
41 |
$1K |
| D1206 |
Topical application of fluoride varnish |
53 |
53 |
$972.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
37 |
37 |
$599.40 |