| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,458 |
2,456 |
$86K |
| D0120 |
Periodic oral evaluation - established patient |
2,032 |
2,030 |
$41K |
| D0220 |
Intraoral - periapical first radiographic image |
3,435 |
3,380 |
$33K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
569 |
359 |
$31K |
| D0330 |
Panoramic radiographic image |
1,339 |
1,337 |
$31K |
| D0274 |
Bitewings - four radiographic images |
1,487 |
1,486 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,036 |
1,036 |
$22K |
| D1120 |
Prophylaxis - child |
378 |
378 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,517 |
2,501 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
1,301 |
1,267 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
153 |
81 |
$5K |
| D2752 |
|
15 |
12 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
313 |
313 |
$4K |
| D9110 |
|
172 |
172 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
36 |
25 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
151 |
147 |
$1K |
| D0272 |
Bitewings - two radiographic images |
39 |
39 |
$490.36 |
| D0350 |
|
13 |
13 |
$136.12 |