| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
685 |
563 |
$36K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
182 |
113 |
$29K |
| D1206 |
Topical application of fluoride varnish |
973 |
785 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
704 |
561 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
166 |
156 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
138 |
133 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
284 |
225 |
$13K |
| D0274 |
Bitewings - four radiographic images |
241 |
218 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
80 |
50 |
$8K |
| D0330 |
Panoramic radiographic image |
51 |
47 |
$4K |
| D1120 |
Prophylaxis - child |
26 |
25 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
47 |
43 |
$1K |
| D4346 |
|
12 |
12 |
$900.00 |
| D9986 |
|
12 |
12 |
$0.00 |