| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
625 |
595 |
$32K |
| D1206 |
Topical application of fluoride varnish |
1,555 |
1,476 |
$32K |
| D0274 |
Bitewings - four radiographic images |
643 |
599 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
549 |
507 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
718 |
687 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
90 |
64 |
$12K |
| D0330 |
Panoramic radiographic image |
224 |
215 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
134 |
87 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
225 |
214 |
$7K |
| D1354 |
|
78 |
26 |
$2K |
| D1120 |
Prophylaxis - child |
37 |
37 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
41 |
39 |
$703.08 |
| D1320 |
|
14 |
14 |
$412.50 |
| D1999 |
|
27 |
23 |
$38.25 |
| D4999 |
|
520 |
501 |
$0.00 |