| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,880 |
1,880 |
$97K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
744 |
485 |
$88K |
| D0120 |
Periodic oral evaluation - established patient |
2,335 |
2,333 |
$62K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
532 |
356 |
$48K |
| D1120 |
Prophylaxis - child |
783 |
783 |
$30K |
| D1206 |
Topical application of fluoride varnish |
1,006 |
1,006 |
$23K |
| D0330 |
Panoramic radiographic image |
54 |
54 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
25 |
25 |
$933.89 |
| D0274 |
Bitewings - four radiographic images |
25 |
25 |
$769.02 |
| D0220 |
Intraoral - periapical first radiographic image |
40 |
40 |
$713.84 |
| D0272 |
Bitewings - two radiographic images |
27 |
27 |
$591.70 |