| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,395 |
2,394 |
$138K |
| D0120 |
Periodic oral evaluation - established patient |
4,096 |
4,095 |
$118K |
| D1120 |
Prophylaxis - child |
1,618 |
1,618 |
$72K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
586 |
526 |
$57K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,609 |
2,609 |
$38K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
100 |
94 |
$12K |
| D0272 |
Bitewings - two radiographic images |
603 |
602 |
$10K |
| D0330 |
Panoramic radiographic image |
71 |
71 |
$3K |
| D0274 |
Bitewings - four radiographic images |
26 |
26 |
$821.02 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
17 |
17 |
$510.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$203.00 |
| D1999 |
|
148 |
128 |
$0.00 |