| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
275 |
271 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
201 |
101 |
$10K |
| D0999 |
Unspecified diagnostic procedure, by report |
236 |
194 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
346 |
335 |
$7K |
| D0274 |
Bitewings - four radiographic images |
269 |
264 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
13 |
$2K |
| D1330 |
|
440 |
425 |
$1K |
| D1120 |
Prophylaxis - child |
50 |
43 |
$529.72 |
| D1999 |
|
52 |
42 |
$495.67 |
| D0220 |
Intraoral - periapical first radiographic image |
289 |
283 |
$329.66 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
12 |
$288.98 |
| D4921 |
|
199 |
91 |
$187.26 |
| D0230 |
Intraoral - periapical each additional radiographic image |
216 |
211 |
$119.50 |
| D1206 |
Topical application of fluoride varnish |
363 |
351 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
41 |
38 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
34 |
32 |
$0.00 |