| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
751 |
751 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
533 |
533 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
185 |
133 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,165 |
1,123 |
$10K |
| D0274 |
Bitewings - four radiographic images |
440 |
439 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
319 |
319 |
$7K |
| D0330 |
Panoramic radiographic image |
204 |
204 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
623 |
620 |
$5K |
| D0350 |
|
655 |
655 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
80 |
55 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
61 |
61 |
$689.90 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$129.85 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$89.24 |