| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
965 |
932 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
1,837 |
1,770 |
$36K |
| D0274 |
Bitewings - four radiographic images |
1,175 |
1,125 |
$33K |
| D1354 |
|
701 |
89 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
387 |
345 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
170 |
117 |
$6K |
| D1355 |
|
64 |
13 |
$5K |
| D4910 |
|
39 |
38 |
$5K |
| D1206 |
Topical application of fluoride varnish |
262 |
255 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
632 |
355 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
110 |
108 |
$1K |
| D0330 |
Panoramic radiographic image |
32 |
32 |
$1K |
| D2940 |
|
97 |
63 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
161 |
100 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
13 |
$1K |
| D1120 |
Prophylaxis - child |
30 |
30 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
144 |
133 |
$974.53 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
68 |
51 |
$943.50 |
| D1351 |
Sealant - per tooth |
434 |
66 |
$645.70 |
| D1208 |
Topical application of fluoride, excluding varnish |
60 |
60 |
$89.56 |