| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,138 |
1,136 |
$94K |
| D0120 |
Periodic oral evaluation - established patient |
1,667 |
1,663 |
$91K |
| D9430 |
|
1,391 |
874 |
$42K |
| D1120 |
Prophylaxis - child |
922 |
921 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
441 |
441 |
$26K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
396 |
197 |
$26K |
| D0274 |
Bitewings - four radiographic images |
1,157 |
1,156 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,208 |
1,206 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,555 |
1,659 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
217 |
216 |
$10K |
| D0330 |
Panoramic radiographic image |
200 |
200 |
$6K |
| D1320 |
|
298 |
297 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
103 |
100 |
$1K |
| D9995 |
|
560 |
473 |
$571.50 |
| D0350 |
|
27 |
14 |
$240.00 |
| D0703 |
|
27 |
14 |
$0.00 |
| D1999 |
|
152 |
147 |
$0.00 |