| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
893 |
891 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
1,013 |
1,008 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
140 |
86 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
189 |
186 |
$7K |
| D0274 |
Bitewings - four radiographic images |
254 |
253 |
$5K |
| D1120 |
Prophylaxis - child |
44 |
44 |
$2K |
| D0330 |
Panoramic radiographic image |
41 |
41 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
22 |
22 |
$650.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$168.00 |
| D1999 |
|
48 |
46 |
$0.00 |
| D0190 |
|
14 |
14 |
$0.00 |