| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,874 |
1,871 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
1,559 |
1,557 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,020 |
1,020 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
290 |
133 |
$4K |
| D0274 |
Bitewings - four radiographic images |
1,427 |
1,418 |
$4K |
| D0330 |
Panoramic radiographic image |
532 |
532 |
$4K |
| D1120 |
Prophylaxis - child |
266 |
266 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
2,157 |
2,139 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
286 |
286 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,012 |
2,001 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
98 |
39 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
40 |
27 |
$85.00 |
| D8660 |
|
12 |
12 |
$0.00 |