| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,067 |
2,056 |
$110K |
| D0120 |
Periodic oral evaluation - established patient |
3,171 |
3,158 |
$89K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
979 |
589 |
$72K |
| D1120 |
Prophylaxis - child |
1,485 |
1,479 |
$54K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,458 |
3,444 |
$51K |
| D0274 |
Bitewings - four radiographic images |
1,264 |
1,260 |
$43K |
| D0272 |
Bitewings - two radiographic images |
767 |
764 |
$18K |
| D0210 |
Intraoral - complete series of radiographic images |
140 |
140 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
137 |
134 |
$5K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$550.62 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$263.05 |
| D0602 |
|
1,191 |
1,185 |
$0.00 |
| D0601 |
|
2,270 |
2,259 |
$0.00 |
| D0603 |
|
12 |
12 |
$0.00 |