| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
581 |
574 |
$21K |
| D1206 |
Topical application of fluoride varnish |
1,055 |
1,038 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
250 |
182 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
771 |
759 |
$14K |
| D4341 |
|
352 |
81 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
208 |
138 |
$10K |
| D0274 |
Bitewings - four radiographic images |
443 |
433 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
300 |
290 |
$6K |
| D4910 |
|
135 |
133 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
48 |
37 |
$3K |
| D1120 |
Prophylaxis - child |
102 |
102 |
$3K |
| D1999 |
|
263 |
189 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
227 |
222 |
$2K |
| D2331 |
|
21 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
43 |
43 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
53 |
50 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
16 |
16 |
$715.82 |
| D0230 |
Intraoral - periapical each additional radiographic image |
63 |
40 |
$309.96 |