| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,057 |
1,027 |
$52K |
| D0274 |
Bitewings - four radiographic images |
840 |
812 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
1,040 |
1,002 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
1,181 |
1,111 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,065 |
904 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
127 |
78 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
200 |
196 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
142 |
61 |
$7K |
| D0330 |
Panoramic radiographic image |
183 |
181 |
$5K |
| D1206 |
Topical application of fluoride varnish |
178 |
175 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
112 |
103 |
$4K |
| D1120 |
Prophylaxis - child |
66 |
66 |
$3K |
| D1330 |
|
43 |
43 |
$28.00 |