| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,047 |
2,042 |
$66K |
| D0330 |
Panoramic radiographic image |
910 |
906 |
$56K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
787 |
460 |
$52K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,018 |
586 |
$38K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,230 |
1,223 |
$15K |
| D1120 |
Prophylaxis - child |
361 |
361 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
1,516 |
1,510 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,627 |
2,621 |
$4K |
| D0274 |
Bitewings - four radiographic images |
1,952 |
1,943 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
39 |
38 |
$2K |
| D1330 |
|
2,630 |
2,624 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
14 |
$733.00 |
| D0220 |
Intraoral - periapical first radiographic image |
2,424 |
2,406 |
$576.04 |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,435 |
2,370 |
$504.62 |
| D0140 |
Limited oral evaluation - problem focused |
24 |
24 |
$287.90 |
| D1999 |
|
14 |
13 |
$0.00 |