| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,391 |
3,391 |
$142K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,871 |
1,123 |
$136K |
| D0120 |
Periodic oral evaluation - established patient |
3,191 |
3,191 |
$70K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
967 |
572 |
$46K |
| D0210 |
Intraoral - complete series of radiographic images |
982 |
982 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
999 |
999 |
$22K |
| D0274 |
Bitewings - four radiographic images |
886 |
886 |
$20K |
| D1120 |
Prophylaxis - child |
519 |
519 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
960 |
960 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
523 |
523 |
$8K |
| D9110 |
|
379 |
373 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
296 |
296 |
$4K |
| D1206 |
Topical application of fluoride varnish |
141 |
141 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
39 |
27 |
$3K |
| D0330 |
Panoramic radiographic image |
104 |
104 |
$3K |