| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
682 |
671 |
$31K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
168 |
127 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
784 |
760 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
243 |
167 |
$8K |
| D0330 |
Panoramic radiographic image |
222 |
218 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
270 |
268 |
$4K |
| D9920 |
|
28 |
28 |
$3K |
| D1120 |
Prophylaxis - child |
163 |
158 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
691 |
675 |
$1K |
| D2332 |
|
21 |
12 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
45 |
33 |
$666.25 |
| D0140 |
Limited oral evaluation - problem focused |
71 |
70 |
$583.65 |
| D0220 |
Intraoral - periapical first radiographic image |
770 |
744 |
$402.78 |
| D0274 |
Bitewings - four radiographic images |
604 |
588 |
$284.97 |
| D1330 |
|
1,005 |
988 |
$253.81 |
| D0230 |
Intraoral - periapical each additional radiographic image |
684 |
663 |
$192.05 |
| D0601 |
|
32 |
32 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$0.00 |
| D3120 |
|
14 |
12 |
$0.00 |