| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,166 |
1,163 |
$37K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
489 |
241 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
1,210 |
1,207 |
$26K |
| D0210 |
Intraoral - complete series of radiographic images |
451 |
451 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
637 |
594 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
345 |
338 |
$7K |
| D0274 |
Bitewings - four radiographic images |
333 |
333 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
220 |
220 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
57 |
37 |
$3K |
| D1120 |
Prophylaxis - child |
104 |
104 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
288 |
282 |
$1K |
| D1999 |
|
47 |
41 |
$460.00 |
| D1206 |
Topical application of fluoride varnish |
16 |
16 |
$414.70 |
| D0330 |
Panoramic radiographic image |
59 |
59 |
$381.25 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$182.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
42 |
33 |
$132.10 |