| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,843 |
2,520 |
$101K |
| D0120 |
Periodic oral evaluation - established patient |
2,653 |
2,345 |
$48K |
| D0274 |
Bitewings - four radiographic images |
2,081 |
1,870 |
$42K |
| D2394 |
|
358 |
182 |
$25K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
364 |
192 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
320 |
162 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
298 |
154 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
540 |
514 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
810 |
740 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
193 |
163 |
$8K |
| D0330 |
Panoramic radiographic image |
117 |
117 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
921 |
480 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
856 |
813 |
$4K |
| D1120 |
Prophylaxis - child |
146 |
142 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
65 |
65 |
$1K |
| D0272 |
Bitewings - two radiographic images |
29 |
29 |
$260.00 |