| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
320 |
311 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
413 |
395 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
66 |
29 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
88 |
27 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
48 |
16 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
118 |
104 |
$6K |
| D0274 |
Bitewings - four radiographic images |
180 |
171 |
$5K |
| D0180 |
|
84 |
84 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
303 |
284 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
273 |
255 |
$3K |
| D0330 |
Panoramic radiographic image |
38 |
38 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
65 |
65 |
$2K |
| D0460 |
|
65 |
65 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
24 |
24 |
$1K |