| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,091 |
1,089 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
867 |
865 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
368 |
244 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
204 |
160 |
$6K |
| D0274 |
Bitewings - four radiographic images |
837 |
837 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
1,099 |
1,055 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
224 |
224 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
847 |
808 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
199 |
194 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
14 |
$485.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
53 |
53 |
$356.00 |
| D1120 |
Prophylaxis - child |
18 |
18 |
$180.00 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$60.00 |