| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,079 |
1,071 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
1,179 |
1,170 |
$18K |
| D0274 |
Bitewings - four radiographic images |
578 |
573 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
164 |
97 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
200 |
90 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
83 |
36 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
402 |
402 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
165 |
161 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
369 |
318 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
101 |
92 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
45 |
45 |
$1K |
| D1120 |
Prophylaxis - child |
28 |
28 |
$938.56 |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$755.86 |
| D2752 |
|
20 |
13 |
$0.00 |