| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
409 |
382 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
658 |
611 |
$14K |
| D1206 |
Topical application of fluoride varnish |
481 |
454 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
75 |
39 |
$6K |
| D0274 |
Bitewings - four radiographic images |
149 |
139 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
124 |
120 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
46 |
44 |
$2K |
| D0330 |
Panoramic radiographic image |
26 |
24 |
$1K |
| D1120 |
Prophylaxis - child |
12 |
12 |
$414.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$173.61 |
| D1999 |
|
17 |
15 |
$10.00 |