| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
290 |
285 |
$14K |
| D1110 |
Prophylaxis - adult |
306 |
294 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
523 |
507 |
$9K |
| D1206 |
Topical application of fluoride varnish |
500 |
493 |
$7K |
| D0274 |
Bitewings - four radiographic images |
180 |
176 |
$5K |
| D0330 |
Panoramic radiographic image |
103 |
99 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
61 |
43 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
96 |
90 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
13 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
29 |
25 |
$727.65 |
| D0272 |
Bitewings - two radiographic images |
26 |
26 |
$496.86 |
| D0220 |
Intraoral - periapical first radiographic image |
66 |
53 |
$450.24 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
12 |
$75.06 |
| D9986 |
|
257 |
243 |
$0.00 |