| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
714 |
714 |
$47K |
| D0120 |
Periodic oral evaluation - established patient |
1,029 |
1,029 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
55 |
52 |
$7K |
| D0274 |
Bitewings - four radiographic images |
177 |
177 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
133 |
133 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
53 |
53 |
$2K |
| D1120 |
Prophylaxis - child |
33 |
33 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
13 |
13 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
35 |
35 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
40 |
39 |
$644.00 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$414.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$215.05 |
| D1999 |
|
132 |
120 |
$0.00 |