| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
163 |
159 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
264 |
261 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
173 |
172 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
111 |
100 |
$2K |
| D1120 |
Prophylaxis - child |
133 |
126 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
27 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
18 |
17 |
$645.48 |
| D0350 |
|
15 |
15 |
$352.80 |
| D0220 |
Intraoral - periapical first radiographic image |
38 |
38 |
$295.80 |