| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,811 |
1,811 |
$100K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
749 |
554 |
$61K |
| D0120 |
Periodic oral evaluation - established patient |
1,684 |
1,683 |
$48K |
| D0274 |
Bitewings - four radiographic images |
981 |
981 |
$28K |
| D0330 |
Panoramic radiographic image |
438 |
438 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
219 |
152 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
359 |
359 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
154 |
151 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
156 |
153 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
12 |
12 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
83 |
83 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
29 |
29 |
$410.90 |
| D1999 |
|
58 |
52 |
$0.00 |