| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
750 |
723 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
1,169 |
1,129 |
$26K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
234 |
138 |
$17K |
| D1120 |
Prophylaxis - child |
507 |
491 |
$16K |
| D1206 |
Topical application of fluoride varnish |
777 |
747 |
$15K |
| D0274 |
Bitewings - four radiographic images |
389 |
369 |
$8K |
| D0272 |
Bitewings - two radiographic images |
241 |
233 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
49 |
32 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
104 |
102 |
$3K |
| D0330 |
Panoramic radiographic image |
17 |
15 |
$619.13 |
| D0220 |
Intraoral - periapical first radiographic image |
30 |
30 |
$367.72 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$317.69 |
| D0230 |
Intraoral - periapical each additional radiographic image |
31 |
30 |
$292.50 |
| D0250 |
|
248 |
168 |
$0.00 |