| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,089 |
2,088 |
$107K |
| D0120 |
Periodic oral evaluation - established patient |
2,685 |
2,682 |
$77K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
914 |
517 |
$70K |
| D1206 |
Topical application of fluoride varnish |
1,890 |
1,889 |
$68K |
| D1120 |
Prophylaxis - child |
895 |
895 |
$46K |
| D0330 |
Panoramic radiographic image |
560 |
560 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
326 |
190 |
$20K |
| D0274 |
Bitewings - four radiographic images |
1,385 |
1,384 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
336 |
333 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
374 |
374 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
61 |
40 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
218 |
193 |
$1K |
| D0601 |
|
89 |
89 |
$979.00 |
| D0160 |
|
15 |
15 |
$675.00 |
| D0602 |
|
18 |
18 |
$198.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$45.00 |