| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,895 |
1,893 |
$54K |
| D0120 |
Periodic oral evaluation - established patient |
2,264 |
2,259 |
$39K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
523 |
293 |
$35K |
| D0330 |
Panoramic radiographic image |
941 |
941 |
$22K |
| D0274 |
Bitewings - four radiographic images |
941 |
941 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
233 |
180 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
1,030 |
1,029 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,202 |
1,202 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
736 |
736 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
68 |
68 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
26 |
$1K |
| D2394 |
|
16 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
86 |
81 |
$823.64 |
| D9110 |
|
71 |
63 |
$731.80 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$390.00 |
| D0272 |
Bitewings - two radiographic images |
43 |
43 |
$372.50 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$154.25 |