| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,450 |
1,448 |
$82K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
503 |
486 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
1,769 |
1,767 |
$50K |
| D1120 |
Prophylaxis - child |
367 |
367 |
$16K |
| D0274 |
Bitewings - four radiographic images |
531 |
530 |
$15K |
| D0330 |
Panoramic radiographic image |
174 |
174 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
442 |
442 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
109 |
109 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
44 |
43 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
65 |
64 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
76 |
76 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
60 |
57 |
$826.00 |