| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
560 |
552 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
826 |
814 |
$12K |
| D0274 |
Bitewings - four radiographic images |
488 |
486 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
164 |
159 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
74 |
41 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
14 |
$2K |
| D0330 |
Panoramic radiographic image |
52 |
52 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
108 |
108 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
33 |
33 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
123 |
113 |
$979.20 |
| D0140 |
Limited oral evaluation - problem focused |
17 |
17 |
$422.11 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$402.24 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
12 |
$0.00 |