| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,507 |
3,506 |
$152K |
| D2752 |
|
237 |
205 |
$106K |
| D0274 |
Bitewings - four radiographic images |
3,558 |
3,558 |
$80K |
| D0120 |
Periodic oral evaluation - established patient |
2,856 |
2,856 |
$65K |
| D0220 |
Intraoral - periapical first radiographic image |
3,103 |
3,091 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,249 |
1,247 |
$28K |
| D0210 |
Intraoral - complete series of radiographic images |
1,233 |
1,228 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,633 |
2,631 |
$17K |
| D2335 |
|
122 |
99 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
230 |
167 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
255 |
182 |
$11K |
| D2332 |
|
137 |
72 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
102 |
84 |
$8K |
| D2954 |
|
74 |
69 |
$7K |
| D1120 |
Prophylaxis - child |
106 |
106 |
$4K |
| D2394 |
|
33 |
28 |
$2K |
| D1320 |
|
272 |
272 |
$2K |
| D9110 |
|
49 |
49 |
$822.69 |
| D1208 |
Topical application of fluoride, excluding varnish |
63 |
63 |
$699.10 |
| D9990 |
|
29 |
29 |
$638.00 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$218.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$150.41 |