| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,213 |
1,212 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,271 |
1,270 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
294 |
143 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
1,605 |
1,580 |
$6K |
| D0274 |
Bitewings - four radiographic images |
682 |
682 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
272 |
267 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,107 |
1,105 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
123 |
94 |
$3K |
| D1120 |
Prophylaxis - child |
133 |
133 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
135 |
135 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
234 |
234 |
$936.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
13 |
$534.60 |
| D0330 |
Panoramic radiographic image |
26 |
26 |
$237.60 |
| D0272 |
Bitewings - two radiographic images |
46 |
46 |
$159.50 |