| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
544 |
527 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
167 |
65 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
326 |
325 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
309 |
300 |
$8K |
| D0330 |
Panoramic radiographic image |
274 |
264 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
569 |
553 |
$3K |
| D0274 |
Bitewings - four radiographic images |
211 |
196 |
$2K |
| D2954 |
|
47 |
28 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
394 |
370 |
$2K |
| D1206 |
Topical application of fluoride varnish |
254 |
244 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
74 |
74 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
122 |
114 |
$1K |
| D1120 |
Prophylaxis - child |
13 |
13 |
$585.00 |
| D0601 |
|
194 |
179 |
$470.00 |
| D0272 |
Bitewings - two radiographic images |
26 |
26 |
$260.00 |
| D1204 |
|
28 |
28 |
$0.00 |