| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,200 |
1,192 |
$61K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
718 |
535 |
$54K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,061 |
1,054 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
1,221 |
1,217 |
$34K |
| D1120 |
Prophylaxis - child |
1,038 |
1,035 |
$31K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
449 |
358 |
$28K |
| D0274 |
Bitewings - four radiographic images |
762 |
759 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
770 |
768 |
$18K |
| D0330 |
Panoramic radiographic image |
231 |
225 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
440 |
429 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
104 |
81 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
782 |
767 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
772 |
376 |
$5K |
| D0272 |
Bitewings - two radiographic images |
143 |
143 |
$2K |
| D2331 |
|
14 |
12 |
$920.56 |
| D1999 |
|
214 |
187 |
$0.00 |