| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,335 |
1,308 |
$69K |
| D0120 |
Periodic oral evaluation - established patient |
1,635 |
1,588 |
$39K |
| D1208 |
Topical application of fluoride, excluding varnish |
893 |
855 |
$25K |
| D0274 |
Bitewings - four radiographic images |
635 |
622 |
$22K |
| D1120 |
Prophylaxis - child |
457 |
444 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,144 |
1,090 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
198 |
113 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
365 |
356 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,042 |
811 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
231 |
223 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
57 |
56 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
36 |
25 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
22 |
15 |
$2K |
| D0330 |
Panoramic radiographic image |
41 |
41 |
$2K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$304.00 |
| D0270 |
|
15 |
15 |
$195.00 |