| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,342 |
2,340 |
$97K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
889 |
673 |
$74K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
747 |
586 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
2,247 |
2,246 |
$47K |
| D0274 |
Bitewings - four radiographic images |
1,913 |
1,911 |
$39K |
| D0140 |
Limited oral evaluation - problem focused |
1,396 |
1,259 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,543 |
1,509 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
579 |
578 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
473 |
463 |
$9K |
| D0330 |
Panoramic radiographic image |
468 |
467 |
$9K |
| D2394 |
|
66 |
56 |
$8K |
| D1120 |
Prophylaxis - child |
225 |
225 |
$7K |
| D0270 |
|
213 |
212 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
146 |
146 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
143 |
141 |
$712.46 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$188.50 |
| D1310 |
|
12 |
12 |
$0.00 |
| D1330 |
|
12 |
12 |
$0.00 |