| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,659 |
1,648 |
$55K |
| D0210 |
Intraoral - complete series of radiographic images |
657 |
657 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,333 |
1,322 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
570 |
395 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
1,403 |
1,395 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
363 |
360 |
$14K |
| D1120 |
Prophylaxis - child |
329 |
325 |
$11K |
| D1206 |
Topical application of fluoride varnish |
425 |
420 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
2,294 |
2,265 |
$6K |
| D0274 |
Bitewings - four radiographic images |
1,296 |
1,286 |
$6K |
| D0330 |
Panoramic radiographic image |
1,013 |
1,008 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,659 |
1,834 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
149 |
107 |
$4K |
| D0272 |
Bitewings - two radiographic images |
24 |
24 |
$96.00 |
| D1999 |
|
1,320 |
1,145 |
$0.00 |