| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,799 |
1,799 |
$98K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
540 |
437 |
$66K |
| D0274 |
Bitewings - four radiographic images |
1,779 |
1,779 |
$48K |
| D0120 |
Periodic oral evaluation - established patient |
1,656 |
1,656 |
$45K |
| D1120 |
Prophylaxis - child |
645 |
645 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
774 |
774 |
$23K |
| D0330 |
Panoramic radiographic image |
590 |
590 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
996 |
996 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
547 |
540 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
337 |
330 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
31 |
28 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
208 |
199 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
36 |
36 |
$266.00 |
| D1999 |
|
74 |
68 |
$0.00 |