| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
746 |
726 |
$45K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
814 |
445 |
$38K |
| D1120 |
Prophylaxis - child |
685 |
664 |
$34K |
| D0210 |
Intraoral - complete series of radiographic images |
768 |
748 |
$32K |
| D0330 |
Panoramic radiographic image |
1,251 |
1,213 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,211 |
1,179 |
$9K |
| D4341 |
|
232 |
89 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,232 |
1,171 |
$4K |
| D0274 |
Bitewings - four radiographic images |
894 |
872 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
913 |
876 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
37 |
25 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
261 |
250 |
$2K |
| D1330 |
|
1,861 |
1,795 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
63 |
49 |
$2K |
| D9920 |
|
83 |
70 |
$739.05 |
| D0272 |
Bitewings - two radiographic images |
72 |
60 |
$455.00 |
| D0603 |
|
165 |
164 |
$120.00 |
| D0220 |
Intraoral - periapical first radiographic image |
76 |
73 |
$101.00 |
| D1999 |
|
28 |
28 |
$98.70 |
| D0350 |
|
39 |
28 |
$81.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
55 |
32 |
$55.00 |
| D4921 |
|
36 |
14 |
$0.00 |