| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,230 |
2,186 |
$75K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
702 |
376 |
$56K |
| D0120 |
Periodic oral evaluation - established patient |
2,494 |
2,458 |
$34K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
575 |
296 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,085 |
901 |
$26K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,290 |
1,274 |
$25K |
| D0274 |
Bitewings - four radiographic images |
1,196 |
1,177 |
$23K |
| D1120 |
Prophylaxis - child |
744 |
737 |
$20K |
| D0330 |
Panoramic radiographic image |
426 |
319 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
503 |
493 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
243 |
240 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,080 |
1,033 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,141 |
592 |
$8K |
| D4355 |
|
30 |
30 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
13 |
$2K |
| D1206 |
Topical application of fluoride varnish |
237 |
232 |
$2K |
| D4910 |
|
12 |
12 |
$0.00 |