| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,149 |
2,137 |
$74K |
| D1206 |
Topical application of fluoride varnish |
2,498 |
2,447 |
$56K |
| D0120 |
Periodic oral evaluation - established patient |
2,346 |
2,334 |
$54K |
| D0274 |
Bitewings - four radiographic images |
1,847 |
1,840 |
$37K |
| D1999 |
|
1,828 |
1,526 |
$18K |
| D1120 |
Prophylaxis - child |
187 |
187 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
100 |
100 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
111 |
111 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
97 |
97 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
13 |
$1K |
| D0330 |
Panoramic radiographic image |
24 |
24 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
140 |
126 |
$808.94 |