| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,304 |
2,304 |
$46K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,111 |
898 |
$43K |
| D1120 |
Prophylaxis - child |
1,044 |
1,044 |
$21K |
| D1110 |
Prophylaxis - adult |
1,045 |
1,045 |
$21K |
| D0274 |
Bitewings - four radiographic images |
1,399 |
1,398 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
584 |
579 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
315 |
276 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,660 |
1,655 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
2,381 |
2,370 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
908 |
908 |
$5K |
| D0272 |
Bitewings - two radiographic images |
547 |
547 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
108 |
108 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
43 |
38 |
$2K |
| D0330 |
Panoramic radiographic image |
44 |
44 |
$880.00 |
| D0270 |
|
274 |
270 |
$816.00 |
| D1999 |
|
138 |
109 |
$0.00 |