| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
771 |
771 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
1,035 |
1,035 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
251 |
163 |
$20K |
| D1120 |
Prophylaxis - child |
328 |
328 |
$14K |
| D0274 |
Bitewings - four radiographic images |
427 |
427 |
$11K |
| D0330 |
Panoramic radiographic image |
248 |
248 |
$8K |
| D1206 |
Topical application of fluoride varnish |
181 |
181 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
94 |
94 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
148 |
148 |
$2K |
| D0272 |
Bitewings - two radiographic images |
96 |
96 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
100 |
100 |
$1K |
| D1999 |
|
139 |
138 |
$0.00 |