| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,372 |
3,317 |
$148K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,223 |
4,083 |
$106K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,309 |
613 |
$103K |
| D0120 |
Periodic oral evaluation - established patient |
3,376 |
3,251 |
$100K |
| D0140 |
Limited oral evaluation - problem focused |
2,704 |
2,223 |
$93K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
725 |
407 |
$72K |
| D0274 |
Bitewings - four radiographic images |
1,677 |
1,620 |
$64K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
519 |
501 |
$29K |
| D0330 |
Panoramic radiographic image |
375 |
364 |
$29K |
| D1110 |
Prophylaxis - adult |
681 |
593 |
$21K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
125 |
75 |
$15K |
| D2394 |
|
84 |
53 |
$12K |
| D0272 |
Bitewings - two radiographic images |
259 |
257 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
574 |
532 |
$7K |
| D2940 |
|
138 |
82 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
72 |
70 |
$4K |
| D9940 |
|
12 |
12 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
44 |
25 |
$468.18 |