| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,408 |
1,407 |
$77K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
545 |
406 |
$64K |
| D0120 |
Periodic oral evaluation - established patient |
1,764 |
1,764 |
$50K |
| D0274 |
Bitewings - four radiographic images |
1,378 |
1,377 |
$41K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,555 |
1,550 |
$39K |
| D1120 |
Prophylaxis - child |
595 |
595 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
289 |
231 |
$25K |
| D0330 |
Panoramic radiographic image |
453 |
453 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
392 |
392 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
817 |
817 |
$12K |
| D0272 |
Bitewings - two radiographic images |
519 |
519 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
31 |
26 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
158 |
157 |
$2K |
| D1206 |
Topical application of fluoride varnish |
66 |
66 |
$2K |
| D2331 |
|
14 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
97 |
96 |
$1K |
| D0240 |
|
14 |
12 |
$408.00 |