| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
6,309 |
6,307 |
$223K |
| D0120 |
Periodic oral evaluation - established patient |
6,805 |
6,801 |
$137K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,236 |
7,230 |
$82K |
| D0272 |
Bitewings - two radiographic images |
6,802 |
6,799 |
$77K |
| D1120 |
Prophylaxis - child |
2,016 |
2,013 |
$63K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,190 |
3,187 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,525 |
1,525 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
569 |
202 |
$30K |
| D0220 |
Intraoral - periapical first radiographic image |
2,240 |
2,240 |
$22K |
| D0210 |
Intraoral - complete series of radiographic images |
1,237 |
1,237 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
342 |
100 |
$12K |
| D2954 |
|
79 |
58 |
$7K |
| D9990 |
|
99 |
99 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
14 |
12 |
$1K |
| D9110 |
|
39 |
37 |
$677.68 |
| D9430 |
|
26 |
26 |
$302.10 |