| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,748 |
1,747 |
$61K |
| D0274 |
Bitewings - four radiographic images |
2,056 |
2,054 |
$59K |
| D1110 |
Prophylaxis - adult |
1,181 |
1,181 |
$53K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,216 |
1,216 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
206 |
136 |
$15K |
| D1120 |
Prophylaxis - child |
280 |
279 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
61 |
25 |
$5K |
| D0330 |
Panoramic radiographic image |
134 |
134 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
289 |
287 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
45 |
36 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
109 |
109 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
37 |
36 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
24 |
24 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
78 |
60 |
$1K |