| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,263 |
1,258 |
$87K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
339 |
166 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
362 |
360 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
391 |
391 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
25 |
$2K |
| D1120 |
Prophylaxis - child |
38 |
38 |
$2K |
| D0274 |
Bitewings - four radiographic images |
1,189 |
1,183 |
$2K |
| D0330 |
Panoramic radiographic image |
60 |
60 |
$924.82 |
| D0120 |
Periodic oral evaluation - established patient |
1,280 |
1,273 |
$684.10 |
| D0220 |
Intraoral - periapical first radiographic image |
618 |
586 |
$249.41 |
| D0230 |
Intraoral - periapical each additional radiographic image |
332 |
134 |
$45.31 |
| D1206 |
Topical application of fluoride varnish |
138 |
138 |
$27.10 |
| D0272 |
Bitewings - two radiographic images |
37 |
37 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
609 |
607 |
$-155.93 |