| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,620 |
2,620 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,847 |
1,845 |
$26K |
| D0210 |
Intraoral - complete series of radiographic images |
872 |
871 |
$21K |
| D4341 |
|
850 |
335 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
969 |
849 |
$15K |
| D1206 |
Topical application of fluoride varnish |
3,596 |
3,584 |
$15K |
| D0274 |
Bitewings - four radiographic images |
2,735 |
2,734 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
1,074 |
1,057 |
$12K |
| D0330 |
Panoramic radiographic image |
1,483 |
1,476 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
1,963 |
1,963 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
471 |
442 |
$9K |
| D0603 |
|
3,146 |
3,141 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
3,156 |
3,126 |
$8K |
| D4910 |
|
633 |
632 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,917 |
2,377 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
606 |
489 |
$7K |
| D1120 |
Prophylaxis - child |
554 |
554 |
$3K |
| D2335 |
|
88 |
68 |
$3K |
| D1320 |
|
772 |
761 |
$2K |
| D0170 |
|
189 |
186 |
$1K |
| D2394 |
|
68 |
64 |
$1K |
| D0270 |
|
348 |
346 |
$1K |
| D0602 |
|
283 |
283 |
$968.01 |
| D4342 |
|
58 |
29 |
$897.00 |
| D2331 |
|
17 |
12 |
$288.00 |
| D0272 |
Bitewings - two radiographic images |
111 |
111 |
$260.00 |
| D0601 |
|
38 |
38 |
$121.00 |
| D1330 |
|
5,414 |
5,244 |
$90.00 |
| D1310 |
|
5,411 |
5,245 |
$50.00 |
| D1354 |
|
32 |
16 |
$8.00 |
| D4921 |
|
1,061 |
420 |
$0.00 |