| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
373 |
371 |
$13K |
| D0274 |
Bitewings - four radiographic images |
216 |
215 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
282 |
282 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
62 |
29 |
$4K |
| D0330 |
Panoramic radiographic image |
94 |
94 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
123 |
122 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
105 |
67 |
$1K |
| D9110 |
|
26 |
25 |
$730.00 |
| D0220 |
Intraoral - periapical first radiographic image |
103 |
101 |
$712.00 |
| D1206 |
Topical application of fluoride varnish |
24 |
24 |
$414.00 |
| D1999 |
|
17 |
14 |
$0.00 |