| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,122 |
3,107 |
$125K |
| D0120 |
Periodic oral evaluation - established patient |
2,869 |
2,856 |
$55K |
| D0274 |
Bitewings - four radiographic images |
1,409 |
1,405 |
$36K |
| D0220 |
Intraoral - periapical first radiographic image |
249 |
242 |
$3K |
| D0330 |
Panoramic radiographic image |
54 |
54 |
$2K |
| D1206 |
Topical application of fluoride varnish |
56 |
56 |
$1K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
19 |
13 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
28 |
28 |
$425.47 |
| D1330 |
|
54 |
51 |
$275.10 |
| D0230 |
Intraoral - periapical each additional radiographic image |
23 |
13 |
$244.48 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
15 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
14 |
$0.00 |
| D1120 |
Prophylaxis - child |
14 |
14 |
$0.00 |