| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,428 |
1,428 |
$63K |
| D0120 |
Periodic oral evaluation - established patient |
1,819 |
1,818 |
$40K |
| D0272 |
Bitewings - two radiographic images |
1,279 |
1,279 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,041 |
1,041 |
$12K |
| D1120 |
Prophylaxis - child |
220 |
220 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
104 |
104 |
$2K |
| D0330 |
Panoramic radiographic image |
52 |
52 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
13 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
68 |
68 |
$729.34 |
| D9999 |
Unspecified adjunctive procedure, by report |
29 |
29 |
$0.00 |
| D1999 |
|
42 |
42 |
$0.00 |