| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
838 |
837 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
1,065 |
1,063 |
$29K |
| D0274 |
Bitewings - four radiographic images |
664 |
663 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
222 |
141 |
$17K |
| D1120 |
Prophylaxis - child |
215 |
215 |
$9K |
| D0330 |
Panoramic radiographic image |
116 |
116 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
340 |
340 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
64 |
40 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
68 |
68 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
58 |
56 |
$679.10 |
| D1330 |
|
15 |
15 |
$0.00 |