| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
699 |
699 |
$33K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
239 |
127 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
1,074 |
1,071 |
$27K |
| D1120 |
Prophylaxis - child |
354 |
353 |
$13K |
| D0274 |
Bitewings - four radiographic images |
371 |
371 |
$8K |
| D0330 |
Panoramic radiographic image |
115 |
115 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
320 |
320 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
140 |
140 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
41 |
40 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$219.00 |