| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
746 |
728 |
$17K |
| D0274 |
Bitewings - four radiographic images |
635 |
621 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
510 |
496 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
426 |
244 |
$6K |
| D1206 |
Topical application of fluoride varnish |
389 |
376 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
269 |
268 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
175 |
170 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
198 |
191 |
$482.56 |
| D1120 |
Prophylaxis - child |
57 |
57 |
$421.07 |
| D0330 |
Panoramic radiographic image |
44 |
43 |
$63.07 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
213 |
118 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
89 |
67 |
$0.00 |