| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,307 |
1,302 |
$45K |
| D0330 |
Panoramic radiographic image |
782 |
778 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
998 |
995 |
$26K |
| D0140 |
Limited oral evaluation - problem focused |
444 |
435 |
$14K |
| D0274 |
Bitewings - four radiographic images |
1,086 |
1,082 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
2,229 |
2,177 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
310 |
309 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,760 |
1,732 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
102 |
44 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
27 |
12 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
14 |
$1K |
| D1120 |
Prophylaxis - child |
52 |
52 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$78.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$60.00 |