| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
404 |
403 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
510 |
508 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
165 |
134 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
378 |
377 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
391 |
390 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
155 |
123 |
$8K |
| D4341 |
|
41 |
24 |
$8K |
| D1110 |
Prophylaxis - adult |
137 |
137 |
$7K |
| D0330 |
Panoramic radiographic image |
251 |
250 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
311 |
307 |
$5K |
| D0274 |
Bitewings - four radiographic images |
205 |
203 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
420 |
393 |
$3K |
| D9110 |
|
27 |
27 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
53 |
51 |
$387.52 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$191.20 |
| D0603 |
|
15 |
15 |
$67.50 |
| D0270 |
|
12 |
12 |
$67.20 |