| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
179 |
179 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
245 |
245 |
$7K |
| D0274 |
Bitewings - four radiographic images |
124 |
124 |
$4K |
| D1120 |
Prophylaxis - child |
57 |
57 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
13 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
62 |
62 |
$860.50 |
| D0330 |
Panoramic radiographic image |
15 |
15 |
$695.85 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$368.60 |