| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,501 |
2,424 |
$105K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,859 |
3,758 |
$80K |
| D0120 |
Periodic oral evaluation - established patient |
3,050 |
2,982 |
$74K |
| D0274 |
Bitewings - four radiographic images |
1,830 |
1,773 |
$47K |
| D1120 |
Prophylaxis - child |
1,274 |
1,245 |
$42K |
| D0330 |
Panoramic radiographic image |
731 |
712 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
395 |
258 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
205 |
164 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
438 |
419 |
$13K |
| D0272 |
Bitewings - two radiographic images |
208 |
207 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
29 |
18 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
46 |
43 |
$397.11 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$268.40 |
| D1999 |
|
173 |
154 |
$0.00 |