| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,234 |
1,232 |
$50K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
644 |
234 |
$41K |
| D0274 |
Bitewings - four radiographic images |
1,135 |
1,133 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
793 |
791 |
$18K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
181 |
92 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,185 |
1,167 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
240 |
238 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
465 |
465 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,088 |
1,077 |
$5K |
| D1120 |
Prophylaxis - child |
76 |
76 |
$3K |
| D4341 |
|
46 |
13 |
$2K |
| D0330 |
Panoramic radiographic image |
63 |
62 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
44 |
25 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
108 |
108 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
44 |
41 |
$414.32 |