| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
469 |
461 |
$30K |
| D0140 |
Limited oral evaluation - problem focused |
590 |
511 |
$28K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
114 |
76 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
555 |
545 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
163 |
157 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
251 |
251 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
55 |
39 |
$7K |
| D0330 |
Panoramic radiographic image |
142 |
142 |
$7K |
| D0274 |
Bitewings - four radiographic images |
201 |
194 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
100 |
93 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
236 |
227 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
12 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
31 |
31 |
$2K |
| D1120 |
Prophylaxis - child |
13 |
13 |
$550.81 |
| D3120 |
|
15 |
14 |
$525.00 |
| D1330 |
|
13 |
13 |
$78.00 |