| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
496 |
486 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
486 |
463 |
$11K |
| D0274 |
Bitewings - four radiographic images |
603 |
595 |
$11K |
| D0330 |
Panoramic radiographic image |
102 |
102 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
833 |
784 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
693 |
583 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
76 |
43 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
334 |
324 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
367 |
355 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
90 |
47 |
$2K |
| D9994 |
|
701 |
683 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
74 |
74 |
$2K |
| D1120 |
Prophylaxis - child |
63 |
63 |
$1K |
| D1206 |
Topical application of fluoride varnish |
113 |
112 |
$919.02 |
| D9992 |
|
540 |
522 |
$763.96 |
| D9630 |
|
12 |
12 |
$309.96 |
| D0210 |
Intraoral - complete series of radiographic images |
23 |
12 |
$125.21 |
| D2950 |
|
18 |
14 |
$0.00 |
| D2740 |
Crown - porcelain/ceramic |
27 |
16 |
$0.00 |
| D0270 |
|
13 |
13 |
$0.00 |
| D9920 |
|
30 |
28 |
$0.00 |
| D4355 |
|
12 |
12 |
$0.00 |