| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,707 |
2,697 |
$112K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,611 |
1,134 |
$97K |
| D0120 |
Periodic oral evaluation - established patient |
3,354 |
3,341 |
$72K |
| D0274 |
Bitewings - four radiographic images |
2,485 |
2,478 |
$54K |
| D0220 |
Intraoral - periapical first radiographic image |
3,445 |
3,417 |
$35K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
227 |
190 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,914 |
2,907 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
363 |
289 |
$14K |
| D1120 |
Prophylaxis - child |
224 |
224 |
$7K |
| D1320 |
|
628 |
628 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
324 |
324 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
79 |
78 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
90 |
90 |
$980.64 |
| D0272 |
Bitewings - two radiographic images |
33 |
33 |
$427.64 |