| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
5,117 |
5,113 |
$277K |
| D0274 |
Bitewings - four radiographic images |
4,775 |
4,774 |
$130K |
| D0120 |
Periodic oral evaluation - established patient |
4,690 |
4,682 |
$127K |
| D0220 |
Intraoral - periapical first radiographic image |
5,715 |
5,609 |
$73K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
696 |
613 |
$70K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,069 |
4,023 |
$57K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
231 |
220 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
585 |
585 |
$17K |
| D0330 |
Panoramic radiographic image |
374 |
374 |
$13K |
| D2394 |
|
47 |
47 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
38 |
37 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
759 |
703 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
210 |
210 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
77 |
77 |
$1K |
| D1120 |
Prophylaxis - child |
24 |
24 |
$1K |