| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
539 |
529 |
$18K |
| D0274 |
Bitewings - four radiographic images |
531 |
518 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
373 |
367 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
279 |
278 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
95 |
37 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
89 |
33 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
86 |
85 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
12 |
$548.24 |
| D1120 |
Prophylaxis - child |
111 |
110 |
$476.78 |
| D0120 |
Periodic oral evaluation - established patient |
493 |
482 |
$474.98 |
| D0220 |
Intraoral - periapical first radiographic image |
654 |
639 |
$453.80 |
| D0330 |
Panoramic radiographic image |
138 |
132 |
$392.29 |
| D1330 |
|
201 |
198 |
$181.30 |
| D0230 |
Intraoral - periapical each additional radiographic image |
595 |
582 |
$48.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
200 |
197 |
$47.60 |