| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
735 |
720 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
1,194 |
1,170 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
838 |
814 |
$12K |
| D1120 |
Prophylaxis - child |
612 |
592 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
139 |
127 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
55 |
39 |
$3K |
| D0330 |
Panoramic radiographic image |
65 |
65 |
$3K |
| D0274 |
Bitewings - four radiographic images |
115 |
114 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
39 |
39 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
57 |
57 |
$1K |
| D1206 |
Topical application of fluoride varnish |
82 |
82 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
225 |
215 |
$965.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
13 |
12 |
$797.50 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14 |
12 |
$716.94 |
| D0272 |
Bitewings - two radiographic images |
65 |
63 |
$630.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
35 |
16 |
$165.00 |