| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,134 |
1,129 |
$27K |
| D0330 |
Panoramic radiographic image |
538 |
536 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
1,043 |
1,042 |
$15K |
| D0274 |
Bitewings - four radiographic images |
842 |
841 |
$14K |
| D1206 |
Topical application of fluoride varnish |
1,032 |
1,028 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
550 |
547 |
$9K |
| D1120 |
Prophylaxis - child |
508 |
508 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
550 |
519 |
$6K |
| D1330 |
|
456 |
455 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
455 |
433 |
$3K |
| D0272 |
Bitewings - two radiographic images |
85 |
85 |
$720.72 |
| D0230 |
Intraoral - periapical each additional radiographic image |
18 |
12 |
$122.26 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
47 |
28 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
140 |
84 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
12 |
$0.00 |