| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,186 |
1,180 |
$95K |
| D0120 |
Periodic oral evaluation - established patient |
1,570 |
1,561 |
$81K |
| D1120 |
Prophylaxis - child |
1,408 |
1,395 |
$51K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
846 |
844 |
$50K |
| D9430 |
|
998 |
901 |
$32K |
| D0210 |
Intraoral - complete series of radiographic images |
612 |
610 |
$28K |
| D0274 |
Bitewings - four radiographic images |
861 |
859 |
$18K |
| D1206 |
Topical application of fluoride varnish |
1,024 |
1,019 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,486 |
1,268 |
$10K |
| D0350 |
|
1,063 |
527 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
159 |
81 |
$9K |
| D0330 |
Panoramic radiographic image |
209 |
209 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
42 |
25 |
$3K |
| D0272 |
Bitewings - two radiographic images |
215 |
212 |
$2K |
| D4910 |
|
30 |
30 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
83 |
82 |
$996.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
448 |
441 |
$425.00 |
| D1999 |
|
14 |
14 |
$0.00 |