| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,993 |
2,934 |
$91K |
| D0330 |
Panoramic radiographic image |
1,032 |
1,010 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
2,401 |
2,362 |
$38K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
713 |
436 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
561 |
431 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
793 |
774 |
$19K |
| D0274 |
Bitewings - four radiographic images |
909 |
891 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
742 |
737 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
428 |
410 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
837 |
809 |
$4K |
| D1120 |
Prophylaxis - child |
128 |
119 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
13 |
$1K |
| D2140 |
|
19 |
12 |
$748.80 |
| D0230 |
Intraoral - periapical each additional radiographic image |
54 |
25 |
$232.75 |
| D1999 |
|
27 |
26 |
$0.00 |