| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,913 |
1,913 |
$106K |
| D0120 |
Periodic oral evaluation - established patient |
1,948 |
1,948 |
$54K |
| D0274 |
Bitewings - four radiographic images |
685 |
685 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
851 |
837 |
$12K |
| D0330 |
Panoramic radiographic image |
275 |
275 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
69 |
48 |
$5K |
| D1120 |
Prophylaxis - child |
128 |
128 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
244 |
244 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$399.65 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$175.56 |
| D1999 |
|
566 |
503 |
$0.00 |