| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
45 |
45 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
44 |
44 |
$2K |
| D1110 |
Prophylaxis - adult |
29 |
29 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14 |
13 |
$1K |
| D1120 |
Prophylaxis - child |
30 |
30 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
62 |
62 |
$1K |
| D0272 |
Bitewings - two radiographic images |
41 |
41 |
$778.70 |
| D0120 |
Periodic oral evaluation - established patient |
15 |
15 |
$360.00 |