| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,994 |
1,994 |
$132K |
| D0120 |
Periodic oral evaluation - established patient |
2,066 |
2,066 |
$69K |
| D0274 |
Bitewings - four radiographic images |
893 |
893 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
279 |
229 |
$27K |
| D1120 |
Prophylaxis - child |
324 |
324 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
659 |
659 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
145 |
108 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
213 |
213 |
$7K |
| D0330 |
Panoramic radiographic image |
120 |
120 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
43 |
40 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
266 |
261 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
82 |
82 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$836.52 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$245.16 |