| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
175 |
173 |
$8K |
| D1110 |
Prophylaxis - adult |
145 |
145 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
45 |
32 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
37 |
24 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
170 |
170 |
$5K |
| D0330 |
Panoramic radiographic image |
67 |
66 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
203 |
195 |
$3K |
| D0274 |
Bitewings - four radiographic images |
150 |
150 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
13 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
27 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
130 |
62 |
$1K |
| D1120 |
Prophylaxis - child |
12 |
12 |
$519.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
19 |
19 |
$468.00 |