| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,325 |
3,325 |
$133K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,546 |
707 |
$79K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
822 |
434 |
$59K |
| D0120 |
Periodic oral evaluation - established patient |
2,679 |
2,678 |
$54K |
| D0274 |
Bitewings - four radiographic images |
1,645 |
1,645 |
$33K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
671 |
342 |
$29K |
| D0220 |
Intraoral - periapical first radiographic image |
2,193 |
2,186 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
879 |
879 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,866 |
1,866 |
$18K |
| D1120 |
Prophylaxis - child |
110 |
110 |
$3K |
| D0330 |
Panoramic radiographic image |
67 |
67 |
$1K |
| D2330 |
|
17 |
13 |
$911.06 |
| D2332 |
|
16 |
12 |
$730.20 |
| D0210 |
Intraoral - complete series of radiographic images |
338 |
338 |
$620.54 |
| D1208 |
Topical application of fluoride, excluding varnish |
29 |
29 |
$304.70 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$198.00 |
| D1999 |
|
142 |
142 |
$0.00 |