| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,343 |
1,343 |
$72K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
447 |
279 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
1,318 |
1,318 |
$35K |
| D0274 |
Bitewings - four radiographic images |
721 |
721 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
560 |
560 |
$16K |
| D0330 |
Panoramic radiographic image |
261 |
261 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
107 |
74 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
48 |
40 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
118 |
118 |
$4K |
| D4341 |
|
25 |
12 |
$1K |
| D4910 |
|
16 |
16 |
$849.56 |
| D0220 |
Intraoral - periapical first radiographic image |
38 |
37 |
$479.52 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$161.70 |