| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,632 |
2,614 |
$103K |
| D0120 |
Periodic oral evaluation - established patient |
2,281 |
2,272 |
$100K |
| D0230 |
Intraoral - periapical each additional radiographic image |
14,677 |
3,069 |
$67K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
509 |
266 |
$34K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
575 |
239 |
$31K |
| D0272 |
Bitewings - two radiographic images |
2,311 |
2,299 |
$27K |
| D1110 |
Prophylaxis - adult |
317 |
314 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
375 |
373 |
$24K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
199 |
102 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
140 |
140 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
13 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
79 |
79 |
$892.00 |