| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
859 |
858 |
$46K |
| D0120 |
Periodic oral evaluation - established patient |
839 |
839 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
272 |
161 |
$21K |
| D0274 |
Bitewings - four radiographic images |
560 |
560 |
$15K |
| D0330 |
Panoramic radiographic image |
239 |
239 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
73 |
72 |
$2K |
| D1120 |
Prophylaxis - child |
46 |
46 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
146 |
146 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
66 |
66 |
$913.68 |
| D1208 |
Topical application of fluoride, excluding varnish |
67 |
67 |
$896.95 |
| D1999 |
|
117 |
115 |
$0.00 |