| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,837 |
1,837 |
$101K |
| D0274 |
Bitewings - four radiographic images |
1,861 |
1,861 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
1,732 |
1,732 |
$49K |
| D0330 |
Panoramic radiographic image |
1,263 |
1,263 |
$48K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
304 |
140 |
$24K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
185 |
95 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
765 |
765 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,144 |
1,134 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,411 |
1,388 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
142 |
65 |
$8K |
| D2332 |
|
56 |
25 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
211 |
211 |
$3K |
| D1120 |
Prophylaxis - child |
37 |
37 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$196.00 |