| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
690 |
670 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
1,027 |
990 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
2,093 |
1,941 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,156 |
1,135 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
279 |
68 |
$6K |
| D0274 |
Bitewings - four radiographic images |
789 |
761 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
671 |
625 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,695 |
1,400 |
$4K |
| D2335 |
|
138 |
40 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
112 |
26 |
$2K |
| D1321 |
|
300 |
294 |
$1K |
| D0330 |
Panoramic radiographic image |
104 |
90 |
$1K |
| D1120 |
Prophylaxis - child |
108 |
105 |
$846.82 |
| D0210 |
Intraoral - complete series of radiographic images |
57 |
56 |
$783.34 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
59 |
55 |
$396.50 |
| D2950 |
|
13 |
12 |
$127.01 |
| D1999 |
|
20 |
19 |
$22.50 |