| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,502 |
1,493 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
842 |
839 |
$2K |
| D0274 |
Bitewings - four radiographic images |
768 |
764 |
$912.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
835 |
832 |
$630.00 |
| D0120 |
Periodic oral evaluation - established patient |
1,892 |
1,885 |
$520.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
230 |
180 |
$504.00 |
| D1120 |
Prophylaxis - child |
712 |
709 |
$420.00 |
| D0220 |
Intraoral - periapical first radiographic image |
664 |
634 |
$0.00 |
| D0330 |
Panoramic radiographic image |
470 |
466 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
916 |
896 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
70 |
63 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
725 |
552 |
$0.00 |
| D2750 |
|
12 |
12 |
$0.00 |