| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
384 |
384 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
201 |
201 |
$6K |
| D0272 |
Bitewings - two radiographic images |
116 |
116 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
56 |
56 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
12 |
$1K |
| D1120 |
Prophylaxis - child |
29 |
29 |
$1K |
| D1206 |
Topical application of fluoride varnish |
40 |
40 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
85 |
85 |
$1K |
| D0330 |
Panoramic radiographic image |
17 |
17 |
$727.00 |
| D0140 |
Limited oral evaluation - problem focused |
40 |
39 |
$576.00 |