| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,145 |
1,111 |
$46K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
422 |
213 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
1,268 |
1,226 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,051 |
1,028 |
$21K |
| D0274 |
Bitewings - four radiographic images |
584 |
563 |
$14K |
| D0330 |
Panoramic radiographic image |
167 |
165 |
$7K |
| D1120 |
Prophylaxis - child |
189 |
188 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
151 |
148 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
27 |
17 |
$2K |
| D9110 |
|
12 |
12 |
$536.25 |
| D0272 |
Bitewings - two radiographic images |
27 |
27 |
$464.17 |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$287.00 |
| D0220 |
Intraoral - periapical first radiographic image |
24 |
24 |
$278.96 |
| D1999 |
|
79 |
68 |
$0.00 |