| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,291 |
3,267 |
$119K |
| D0274 |
Bitewings - four radiographic images |
2,720 |
2,711 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
2,588 |
2,574 |
$49K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
483 |
290 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,179 |
1,175 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,925 |
2,491 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
2,522 |
2,500 |
$21K |
| D0330 |
Panoramic radiographic image |
681 |
679 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
386 |
210 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,714 |
1,706 |
$14K |
| D1320 |
|
1,786 |
1,785 |
$12K |
| D1120 |
Prophylaxis - child |
291 |
287 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
293 |
289 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
14 |
$1K |
| D1206 |
Topical application of fluoride varnish |
41 |
41 |
$872.70 |
| D9110 |
|
25 |
25 |
$352.80 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$128.20 |