| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,507 |
2,505 |
$112K |
| D0120 |
Periodic oral evaluation - established patient |
2,241 |
2,240 |
$51K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
559 |
378 |
$42K |
| D0274 |
Bitewings - four radiographic images |
1,679 |
1,678 |
$37K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
461 |
286 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
1,729 |
1,680 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,222 |
1,196 |
$18K |
| D0210 |
Intraoral - complete series of radiographic images |
428 |
424 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
378 |
378 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
581 |
581 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
60 |
38 |
$6K |
| D1120 |
Prophylaxis - child |
154 |
154 |
$5K |
| D4341 |
|
55 |
25 |
$3K |
| D2330 |
|
16 |
15 |
$1K |
| D9945 |
|
12 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
38 |
38 |
$1K |
| D1354 |
|
30 |
14 |
$450.00 |