| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,645 |
2,644 |
$115K |
| D0120 |
Periodic oral evaluation - established patient |
3,267 |
3,263 |
$79K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,013 |
644 |
$72K |
| D2394 |
|
314 |
222 |
$34K |
| D0210 |
Intraoral - complete series of radiographic images |
756 |
755 |
$33K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
356 |
259 |
$31K |
| D0274 |
Bitewings - four radiographic images |
1,267 |
1,266 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
335 |
335 |
$5K |
| D0330 |
Panoramic radiographic image |
141 |
141 |
$4K |
| D1120 |
Prophylaxis - child |
53 |
53 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
56 |
56 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
94 |
94 |
$577.00 |
| D1999 |
|
66 |
64 |
$0.00 |