| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,766 |
1,765 |
$63K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,296 |
603 |
$56K |
| D0120 |
Periodic oral evaluation - established patient |
1,720 |
1,719 |
$34K |
| D0330 |
Panoramic radiographic image |
572 |
572 |
$14K |
| D0274 |
Bitewings - four radiographic images |
589 |
589 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,137 |
1,125 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
374 |
374 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
867 |
854 |
$5K |
| D2330 |
|
57 |
39 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
181 |
181 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
14 |
$1K |
| D1120 |
Prophylaxis - child |
12 |
12 |
$387.81 |
| D0210 |
Intraoral - complete series of radiographic images |
30 |
30 |
$322.83 |
| D0140 |
Limited oral evaluation - problem focused |
30 |
30 |
$299.71 |