| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,066 |
1,032 |
$51K |
| D0274 |
Bitewings - four radiographic images |
854 |
816 |
$28K |
| D0330 |
Panoramic radiographic image |
443 |
426 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
166 |
93 |
$21K |
| D1206 |
Topical application of fluoride varnish |
1,060 |
1,023 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
594 |
574 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
600 |
580 |
$13K |
| D4910 |
|
27 |
27 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
12 |
$1K |
| D9630 |
|
54 |
49 |
$753.61 |
| D0220 |
Intraoral - periapical first radiographic image |
42 |
39 |
$661.89 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$420.72 |
| D1999 |
|
65 |
46 |
$17.00 |