| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,918 |
1,918 |
$71K |
| D0120 |
Periodic oral evaluation - established patient |
2,276 |
2,276 |
$47K |
| D0274 |
Bitewings - four radiographic images |
1,574 |
1,574 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
438 |
306 |
$32K |
| D0210 |
Intraoral - complete series of radiographic images |
978 |
968 |
$30K |
| D0220 |
Intraoral - periapical first radiographic image |
1,226 |
1,207 |
$12K |
| D2750 |
|
21 |
12 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
355 |
355 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
543 |
543 |
$6K |
| D2954 |
|
37 |
26 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
530 |
529 |
$4K |
| D0330 |
Panoramic radiographic image |
97 |
97 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
51 |
38 |
$2K |
| D1120 |
Prophylaxis - child |
42 |
42 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
14 |
$739.50 |
| D0140 |
Limited oral evaluation - problem focused |
65 |
65 |
$681.34 |