| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,694 |
2,692 |
$106K |
| D0274 |
Bitewings - four radiographic images |
2,709 |
2,709 |
$53K |
| D0120 |
Periodic oral evaluation - established patient |
2,636 |
2,634 |
$52K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
726 |
421 |
$30K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,323 |
2,320 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
400 |
271 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
2,210 |
2,202 |
$19K |
| D1120 |
Prophylaxis - child |
537 |
535 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
553 |
552 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
806 |
803 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
398 |
397 |
$7K |
| D0330 |
Panoramic radiographic image |
191 |
191 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
12 |
$910.42 |
| D1320 |
|
28 |
28 |
$218.00 |