| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
89 |
89 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
132 |
129 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
120 |
118 |
$3K |
| D0330 |
Panoramic radiographic image |
31 |
30 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
36 |
36 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
13 |
$2K |
| D1120 |
Prophylaxis - child |
36 |
35 |
$2K |
| D0274 |
Bitewings - four radiographic images |
36 |
36 |
$1K |
| D9999 |
Unspecified adjunctive procedure, by report |
365 |
343 |
$0.00 |