| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,778 |
2,722 |
$143K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,048 |
614 |
$117K |
| D0120 |
Periodic oral evaluation - established patient |
2,497 |
2,475 |
$66K |
| D1206 |
Topical application of fluoride varnish |
2,624 |
2,583 |
$64K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
618 |
318 |
$58K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,010 |
979 |
$44K |
| D0274 |
Bitewings - four radiographic images |
1,829 |
1,791 |
$36K |
| D0330 |
Panoramic radiographic image |
695 |
673 |
$29K |
| D0140 |
Limited oral evaluation - problem focused |
562 |
536 |
$20K |
| D1120 |
Prophylaxis - child |
341 |
340 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
841 |
816 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
28 |
27 |
$249.28 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$195.00 |
| D1330 |
|
26 |
26 |
$156.00 |