| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
612 |
575 |
$19K |
| D0274 |
Bitewings - four radiographic images |
752 |
719 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
446 |
424 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
597 |
577 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,640 |
345 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
123 |
71 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
114 |
56 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
337 |
319 |
$5K |
| D1120 |
Prophylaxis - child |
161 |
155 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
146 |
132 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
546 |
518 |
$2K |
| D1351 |
Sealant - per tooth |
151 |
31 |
$2K |
| D0272 |
Bitewings - two radiographic images |
84 |
78 |
$770.00 |
| D0330 |
Panoramic radiographic image |
14 |
12 |
$416.88 |
| D0210 |
Intraoral - complete series of radiographic images |
21 |
12 |
$258.68 |