| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,264 |
1,233 |
$61K |
| D0120 |
Periodic oral evaluation - established patient |
1,477 |
1,441 |
$37K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
416 |
266 |
$36K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
233 |
174 |
$29K |
| D0274 |
Bitewings - four radiographic images |
703 |
683 |
$20K |
| D1120 |
Prophylaxis - child |
452 |
451 |
$15K |
| D1206 |
Topical application of fluoride varnish |
805 |
787 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
297 |
291 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
561 |
559 |
$10K |
| D0330 |
Panoramic radiographic image |
80 |
79 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
66 |
66 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$3K |
| D0272 |
Bitewings - two radiographic images |
30 |
30 |
$720.00 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$521.00 |
| D9986 |
|
41 |
41 |
$0.00 |