| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,570 |
1,569 |
$77K |
| D0120 |
Periodic oral evaluation - established patient |
2,307 |
2,305 |
$63K |
| D0140 |
Limited oral evaluation - problem focused |
887 |
872 |
$43K |
| D1120 |
Prophylaxis - child |
869 |
867 |
$43K |
| D0191 |
|
2,280 |
2,047 |
$34K |
| D1206 |
Topical application of fluoride varnish |
906 |
904 |
$31K |
| D4355 |
|
162 |
161 |
$20K |
| D0330 |
Panoramic radiographic image |
441 |
441 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
551 |
551 |
$15K |
| D0274 |
Bitewings - four radiographic images |
617 |
617 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
232 |
232 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
518 |
509 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
32 |
25 |
$2K |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$157.50 |
| D1999 |
|
45 |
43 |
$0.00 |