| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,547 |
2,547 |
$95K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
835 |
489 |
$50K |
| D0210 |
Intraoral - complete series of radiographic images |
1,364 |
1,340 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,406 |
1,406 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
1,197 |
1,196 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
1,751 |
1,680 |
$15K |
| D0274 |
Bitewings - four radiographic images |
642 |
642 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,277 |
1,261 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
134 |
89 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
868 |
868 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
151 |
103 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
453 |
446 |
$4K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$323.00 |
| D1999 |
|
317 |
267 |
$0.00 |