| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
247 |
247 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
258 |
258 |
$7K |
| D0274 |
Bitewings - four radiographic images |
232 |
232 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
267 |
267 |
$4K |
| D1120 |
Prophylaxis - child |
66 |
66 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
242 |
242 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
59 |
59 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
13 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
61 |
61 |
$826.00 |
| D0330 |
Panoramic radiographic image |
16 |
16 |
$600.00 |