| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,173 |
1,173 |
$47K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
717 |
717 |
$17K |
| D0330 |
Panoramic radiographic image |
476 |
476 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
1,585 |
1,525 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
584 |
584 |
$12K |
| D0274 |
Bitewings - four radiographic images |
528 |
526 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
164 |
100 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
751 |
739 |
$6K |
| D0350 |
|
1,021 |
1,019 |
$6K |
| D1120 |
Prophylaxis - child |
50 |
50 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
45 |
45 |
$509.10 |
| D0272 |
Bitewings - two radiographic images |
26 |
26 |
$326.39 |
| D1330 |
|
594 |
593 |
$0.00 |
| D1310 |
|
636 |
635 |
$0.00 |
| D0431 |
|
287 |
286 |
$0.00 |
| D1999 |
|
17 |
15 |
$0.00 |