| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
986 |
981 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
715 |
712 |
$20K |
| D0274 |
Bitewings - four radiographic images |
607 |
605 |
$17K |
| D0330 |
Panoramic radiographic image |
372 |
371 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
125 |
89 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
312 |
310 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
56 |
39 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
187 |
182 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
35 |
35 |
$493.10 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$159.60 |
| D1999 |
|
28 |
28 |
$0.00 |