| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,524 |
1,511 |
$59K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
642 |
339 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
2,517 |
2,497 |
$42K |
| D1120 |
Prophylaxis - child |
1,165 |
1,154 |
$36K |
| D1206 |
Topical application of fluoride varnish |
1,739 |
1,718 |
$30K |
| D0274 |
Bitewings - four radiographic images |
1,148 |
1,130 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
313 |
188 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
729 |
727 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
352 |
343 |
$10K |
| D9630 |
|
390 |
385 |
$8K |
| D0330 |
Panoramic radiographic image |
77 |
74 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
413 |
387 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
109 |
106 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
16 |
13 |
$650.07 |
| D4341 |
|
46 |
24 |
$0.00 |
| D4910 |
|
12 |
12 |
$0.00 |