| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,932 |
2,931 |
$158K |
| D0120 |
Periodic oral evaluation - established patient |
3,119 |
3,119 |
$84K |
| D0274 |
Bitewings - four radiographic images |
1,025 |
1,024 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
130 |
115 |
$15K |
| D1120 |
Prophylaxis - child |
294 |
294 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
495 |
495 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
230 |
230 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
64 |
63 |
$842.24 |
| D0330 |
Panoramic radiographic image |
18 |
18 |
$601.60 |
| D0272 |
Bitewings - two radiographic images |
27 |
27 |
$431.46 |
| D1999 |
|
19 |
18 |
$0.00 |