| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
528 |
526 |
$19K |
| D0274 |
Bitewings - four radiographic images |
353 |
352 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
364 |
363 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
103 |
52 |
$5K |
| D0330 |
Panoramic radiographic image |
137 |
137 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
239 |
239 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
73 |
58 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
547 |
543 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
144 |
143 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
405 |
322 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
56 |
56 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
40 |
30 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
20 |
20 |
$349.11 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$342.95 |