| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,486 |
1,483 |
$57K |
| D0120 |
Periodic oral evaluation - established patient |
1,655 |
1,649 |
$36K |
| D0274 |
Bitewings - four radiographic images |
1,095 |
1,091 |
$29K |
| D0330 |
Panoramic radiographic image |
359 |
358 |
$14K |
| D1206 |
Topical application of fluoride varnish |
725 |
725 |
$10K |
| D1120 |
Prophylaxis - child |
360 |
360 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
370 |
369 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
140 |
133 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
303 |
284 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
112 |
53 |
$0.00 |
| D1999 |
|
88 |
69 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
46 |
27 |
$0.00 |