| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
6,137 |
6,137 |
$235K |
| D0120 |
Periodic oral evaluation - established patient |
6,151 |
6,151 |
$128K |
| D0274 |
Bitewings - four radiographic images |
5,265 |
5,265 |
$107K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,384 |
816 |
$87K |
| D0220 |
Intraoral - periapical first radiographic image |
5,541 |
5,531 |
$50K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
624 |
439 |
$48K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,665 |
5,662 |
$29K |
| D1320 |
|
3,216 |
3,216 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
371 |
250 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
363 |
363 |
$14K |
| D2394 |
|
120 |
81 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
472 |
472 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
162 |
162 |
$4K |
| D9945 |
|
27 |
27 |
$3K |
| D2335 |
|
13 |
13 |
$1K |
| D2332 |
|
12 |
12 |
$804.65 |
| D9110 |
|
24 |
24 |
$403.54 |