| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,992 |
1,992 |
$100K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,179 |
1,179 |
$47K |
| D0274 |
Bitewings - four radiographic images |
1,480 |
1,480 |
$39K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
406 |
263 |
$37K |
| D1206 |
Topical application of fluoride varnish |
2,044 |
2,044 |
$33K |
| D0330 |
Panoramic radiographic image |
653 |
653 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
1,356 |
1,356 |
$30K |
| D1120 |
Prophylaxis - child |
450 |
450 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
741 |
738 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
92 |
67 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
151 |
150 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
214 |
202 |
$2K |
| D0272 |
Bitewings - two radiographic images |
80 |
80 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
12 |
12 |
$1K |