| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
1,307 |
1,240 |
$27K |
| D0330 |
Panoramic radiographic image |
407 |
403 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
647 |
640 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
298 |
110 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
280 |
261 |
$14K |
| D0250 |
|
969 |
954 |
$12K |
| D1110 |
Prophylaxis - adult |
108 |
107 |
$3K |
| D2335 |
|
29 |
12 |
$3K |
| D1206 |
Topical application of fluoride varnish |
163 |
161 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
42 |
14 |
$2K |
| D2332 |
|
26 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
100 |
100 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
383 |
111 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
86 |
86 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
303 |
292 |
$1K |
| D1120 |
Prophylaxis - child |
51 |
50 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
13 |
$924.34 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$180.00 |