| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,427 |
1,357 |
$52K |
| D0120 |
Periodic oral evaluation - established patient |
1,753 |
1,584 |
$29K |
| D1206 |
Topical application of fluoride varnish |
1,624 |
1,471 |
$24K |
| D1120 |
Prophylaxis - child |
343 |
343 |
$10K |
| D0274 |
Bitewings - four radiographic images |
257 |
255 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
97 |
92 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
120 |
116 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
14 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
27 |
25 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
12 |
$877.73 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$354.55 |
| D0272 |
Bitewings - two radiographic images |
25 |
25 |
$337.07 |
| D0220 |
Intraoral - periapical first radiographic image |
29 |
28 |
$274.92 |