| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,708 |
1,707 |
$98K |
| D0120 |
Periodic oral evaluation - established patient |
1,600 |
1,600 |
$46K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
187 |
163 |
$22K |
| D0210 |
Intraoral - complete series of radiographic images |
478 |
465 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
557 |
557 |
$16K |
| D0274 |
Bitewings - four radiographic images |
483 |
483 |
$14K |
| D1120 |
Prophylaxis - child |
226 |
226 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
524 |
484 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
43 |
39 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
251 |
251 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
103 |
101 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
13 |
12 |
$935.00 |
| D0330 |
Panoramic radiographic image |
26 |
26 |
$840.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
68 |
67 |
$770.00 |
| D0350 |
|
15 |
15 |
$168.00 |
| D1999 |
|
68 |
61 |
$0.00 |