| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,190 |
1,190 |
$41K |
| D1110 |
Prophylaxis - adult |
820 |
820 |
$36K |
| D1120 |
Prophylaxis - child |
1,167 |
1,167 |
$36K |
| D0274 |
Bitewings - four radiographic images |
913 |
913 |
$26K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,429 |
1,429 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
1,662 |
1,645 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
268 |
143 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,182 |
1,165 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
470 |
470 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
184 |
183 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$626.61 |