| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
656 |
642 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
924 |
904 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
323 |
186 |
$21K |
| D0274 |
Bitewings - four radiographic images |
678 |
662 |
$17K |
| D1206 |
Topical application of fluoride varnish |
842 |
823 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,068 |
1,004 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
177 |
106 |
$10K |
| D1120 |
Prophylaxis - child |
259 |
254 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,115 |
732 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
208 |
206 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
44 |
28 |
$3K |
| D4910 |
|
56 |
54 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
68 |
65 |
$2K |
| D1999 |
|
383 |
306 |
$2K |
| D0330 |
Panoramic radiographic image |
42 |
41 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
12 |
$290.00 |
| D1354 |
|
41 |
12 |
$154.00 |
| D1330 |
|
40 |
39 |
$0.00 |
| D1310 |
|
38 |
38 |
$0.00 |