| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,059 |
1,055 |
$47K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
459 |
308 |
$31K |
| D1206 |
Topical application of fluoride varnish |
900 |
896 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
968 |
964 |
$24K |
| D0210 |
Intraoral - complete series of radiographic images |
287 |
286 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
127 |
87 |
$7K |
| D0274 |
Bitewings - four radiographic images |
590 |
587 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
861 |
855 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
696 |
690 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
127 |
126 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
59 |
59 |
$3K |
| D0330 |
Panoramic radiographic image |
59 |
59 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
13 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
31 |
31 |
$775.00 |
| D9310 |
|
22 |
22 |
$380.00 |