| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
855 |
855 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
471 |
232 |
$24K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
381 |
188 |
$22K |
| D0274 |
Bitewings - four radiographic images |
795 |
794 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
782 |
782 |
$15K |
| D9110 |
|
320 |
314 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
460 |
460 |
$8K |
| D2332 |
|
147 |
54 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
1,057 |
1,049 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
793 |
791 |
$6K |
| D0330 |
Panoramic radiographic image |
80 |
80 |
$2K |
| D0601 |
|
103 |
103 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
62 |
62 |
$996.34 |
| D1330 |
|
145 |
145 |
$735.85 |
| D1310 |
|
133 |
133 |
$675.50 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$270.27 |