| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
928 |
928 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
883 |
883 |
$24K |
| D0274 |
Bitewings - four radiographic images |
653 |
653 |
$17K |
| D0330 |
Panoramic radiographic image |
250 |
250 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
102 |
69 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
79 |
79 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
85 |
84 |
$1K |
| D1120 |
Prophylaxis - child |
14 |
14 |
$616.80 |
| D1208 |
Topical application of fluoride, excluding varnish |
45 |
45 |
$600.60 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$187.60 |
| D1999 |
|
126 |
126 |
$0.00 |