| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,990 |
1,972 |
$82K |
| D0120 |
Periodic oral evaluation - established patient |
2,271 |
2,258 |
$52K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
636 |
626 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
152 |
88 |
$20K |
| D0274 |
Bitewings - four radiographic images |
671 |
665 |
$20K |
| D2991 |
|
377 |
14 |
$19K |
| D1206 |
Topical application of fluoride varnish |
567 |
556 |
$10K |
| D0330 |
Panoramic radiographic image |
108 |
108 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
43 |
27 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
243 |
242 |
$3K |
| D1120 |
Prophylaxis - child |
72 |
68 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
25 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
83 |
83 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
16 |
16 |
$524.96 |