| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,342 |
780 |
$19K |
| D1110 |
Prophylaxis - adult |
785 |
428 |
$14K |
| D1120 |
Prophylaxis - child |
722 |
374 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
178 |
52 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
188 |
81 |
$9K |
| D1206 |
Topical application of fluoride varnish |
560 |
417 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
642 |
200 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
189 |
71 |
$3K |
| D0274 |
Bitewings - four radiographic images |
104 |
64 |
$2K |
| D0330 |
Panoramic radiographic image |
16 |
15 |
$923.25 |
| D0272 |
Bitewings - two radiographic images |
49 |
45 |
$856.00 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
12 |
$137.40 |
| D1999 |
|
123 |
111 |
$0.00 |