| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,039 |
2,039 |
$118K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
691 |
538 |
$71K |
| D0120 |
Periodic oral evaluation - established patient |
1,625 |
1,625 |
$47K |
| D0274 |
Bitewings - four radiographic images |
1,206 |
1,205 |
$32K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
194 |
170 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
500 |
498 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
209 |
186 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
716 |
710 |
$9K |
| D0330 |
Panoramic radiographic image |
265 |
264 |
$8K |
| D2394 |
|
29 |
27 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
174 |
173 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
314 |
300 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
79 |
77 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
27 |
27 |
$371.78 |