| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,626 |
2,482 |
$129K |
| D0120 |
Periodic oral evaluation - established patient |
2,680 |
2,526 |
$62K |
| D0274 |
Bitewings - four radiographic images |
1,757 |
1,662 |
$61K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
675 |
411 |
$54K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
471 |
290 |
$45K |
| D0220 |
Intraoral - periapical first radiographic image |
2,018 |
1,851 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,987 |
1,609 |
$20K |
| D1206 |
Topical application of fluoride varnish |
1,106 |
1,035 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
366 |
324 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
377 |
351 |
$14K |
| D0330 |
Panoramic radiographic image |
203 |
183 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
165 |
162 |
$8K |
| D2394 |
|
34 |
24 |
$4K |
| D1120 |
Prophylaxis - child |
43 |
41 |
$966.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
117 |
113 |
$806.04 |
| D1999 |
|
15 |
15 |
$0.00 |