| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,793 |
1,758 |
$104K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,047 |
526 |
$100K |
| D0120 |
Periodic oral evaluation - established patient |
2,746 |
2,693 |
$78K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,273 |
3,214 |
$73K |
| D1120 |
Prophylaxis - child |
1,330 |
1,307 |
$56K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
383 |
227 |
$48K |
| D0274 |
Bitewings - four radiographic images |
1,482 |
1,454 |
$32K |
| D0330 |
Panoramic radiographic image |
579 |
566 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
2,235 |
2,151 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,060 |
2,018 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
218 |
217 |
$11K |
| D1330 |
|
1,073 |
1,058 |
$7K |
| D0272 |
Bitewings - two radiographic images |
130 |
130 |
$2K |
| D3120 |
|
38 |
26 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$346.08 |