| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,851 |
1,851 |
$104K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
631 |
505 |
$58K |
| D0120 |
Periodic oral evaluation - established patient |
1,631 |
1,631 |
$46K |
| D0274 |
Bitewings - four radiographic images |
1,188 |
1,188 |
$34K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
385 |
318 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
633 |
633 |
$19K |
| D0210 |
Intraoral - complete series of radiographic images |
401 |
399 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
88 |
77 |
$9K |
| D0330 |
Panoramic radiographic image |
198 |
198 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
339 |
336 |
$5K |
| D1120 |
Prophylaxis - child |
28 |
28 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
66 |
66 |
$924.00 |
| D0140 |
Limited oral evaluation - problem focused |
25 |
25 |
$336.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$90.16 |