| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,508 |
3,504 |
$116K |
| D0120 |
Periodic oral evaluation - established patient |
3,791 |
3,789 |
$74K |
| D0274 |
Bitewings - four radiographic images |
3,116 |
3,116 |
$57K |
| D0220 |
Intraoral - periapical first radiographic image |
3,991 |
3,974 |
$37K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
428 |
314 |
$26K |
| D0210 |
Intraoral - complete series of radiographic images |
1,046 |
1,043 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,652 |
3,644 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
275 |
160 |
$10K |
| D1120 |
Prophylaxis - child |
259 |
259 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
169 |
169 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
14 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
95 |
95 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
100 |
100 |
$984.57 |
| D0330 |
Panoramic radiographic image |
41 |
41 |
$420.26 |
| D9110 |
|
14 |
13 |
$212.76 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$145.80 |