| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
268 |
265 |
$11K |
| D1120 |
Prophylaxis - child |
215 |
214 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
150 |
86 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
426 |
423 |
$8K |
| D1206 |
Topical application of fluoride varnish |
441 |
439 |
$6K |
| D0274 |
Bitewings - four radiographic images |
209 |
207 |
$5K |
| D0330 |
Panoramic radiographic image |
62 |
62 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
57 |
57 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
48 |
48 |
$449.04 |
| D0230 |
Intraoral - periapical each additional radiographic image |
32 |
15 |
$214.92 |