| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,238 |
4,237 |
$171K |
| D0120 |
Periodic oral evaluation - established patient |
5,165 |
5,163 |
$104K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,549 |
895 |
$86K |
| D0274 |
Bitewings - four radiographic images |
3,942 |
3,941 |
$76K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,037 |
595 |
$74K |
| D0220 |
Intraoral - periapical first radiographic image |
4,237 |
4,198 |
$40K |
| D2394 |
|
225 |
149 |
$23K |
| D0330 |
Panoramic radiographic image |
515 |
515 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
952 |
952 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
336 |
336 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,577 |
1,577 |
$8K |
| D1120 |
Prophylaxis - child |
190 |
190 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
14 |
$823.75 |
| D1999 |
|
12 |
12 |
$0.00 |