| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
240 |
235 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
311 |
298 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
78 |
54 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
79 |
56 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
55 |
49 |
$3K |
| D0274 |
Bitewings - four radiographic images |
117 |
114 |
$2K |
| D1206 |
Topical application of fluoride varnish |
132 |
130 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
82 |
79 |
$2K |
| D1120 |
Prophylaxis - child |
94 |
90 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
289 |
152 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
75 |
74 |
$1K |
| D1351 |
Sealant - per tooth |
50 |
14 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
188 |
181 |
$910.00 |
| D0340 |
|
19 |
14 |
$792.00 |
| D0330 |
Panoramic radiographic image |
22 |
17 |
$787.44 |
| D0272 |
Bitewings - two radiographic images |
42 |
39 |
$380.00 |
| D0350 |
|
18 |
14 |
$160.03 |