| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D8030 |
|
529 |
525 |
$46K |
| D1110 |
Prophylaxis - adult |
587 |
581 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
773 |
745 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
407 |
400 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
432 |
422 |
$9K |
| D0274 |
Bitewings - four radiographic images |
285 |
277 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
674 |
631 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
209 |
206 |
$3K |
| D0330 |
Panoramic radiographic image |
41 |
41 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
27 |
26 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
220 |
93 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
12 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
14 |
$972.99 |
| D1120 |
Prophylaxis - child |
28 |
27 |
$500.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$120.00 |