| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
839 |
811 |
$37K |
| D0274 |
Bitewings - four radiographic images |
900 |
875 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
937 |
914 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
138 |
83 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
268 |
264 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
484 |
476 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
1,428 |
1,390 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,390 |
1,175 |
$9K |
| D0330 |
Panoramic radiographic image |
111 |
111 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
68 |
43 |
$6K |
| D1120 |
Prophylaxis - child |
227 |
225 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
153 |
150 |
$4K |
| D2394 |
|
12 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
93 |
93 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
12 |
$942.33 |