| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
487 |
487 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
573 |
573 |
$16K |
| D0274 |
Bitewings - four radiographic images |
344 |
344 |
$13K |
| D1120 |
Prophylaxis - child |
153 |
153 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
249 |
249 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
247 |
245 |
$3K |
| D0330 |
Panoramic radiographic image |
65 |
65 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
158 |
158 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
57 |
57 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
13 |
$2K |
| D9110 |
|
12 |
12 |
$342.00 |