| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
5,147 |
5,141 |
$211K |
| D0120 |
Periodic oral evaluation - established patient |
4,651 |
4,645 |
$99K |
| D0274 |
Bitewings - four radiographic images |
3,970 |
3,967 |
$84K |
| D0220 |
Intraoral - periapical first radiographic image |
4,386 |
4,380 |
$45K |
| D0210 |
Intraoral - complete series of radiographic images |
980 |
978 |
$36K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,843 |
4,322 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
799 |
798 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
100 |
66 |
$6K |
| D1120 |
Prophylaxis - child |
127 |
127 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
118 |
116 |
$2K |
| D0272 |
Bitewings - two radiographic images |
126 |
126 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
15 |
$1K |
| D2330 |
|
22 |
13 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
104 |
104 |
$1K |
| D0330 |
Panoramic radiographic image |
30 |
30 |
$340.72 |
| D0603 |
|
12 |
12 |
$12.00 |
| D1330 |
|
143 |
143 |
$0.00 |