| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
241 |
241 |
$9K |
| D1110 |
Prophylaxis - adult |
135 |
135 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
102 |
102 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
28 |
17 |
$4K |
| D1206 |
Topical application of fluoride varnish |
98 |
98 |
$3K |
| D0274 |
Bitewings - four radiographic images |
52 |
52 |
$2K |
| D1120 |
Prophylaxis - child |
55 |
55 |
$2K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$251.02 |