| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,790 |
2,790 |
$94K |
| D0120 |
Periodic oral evaluation - established patient |
4,343 |
4,343 |
$84K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,427 |
771 |
$54K |
| D0210 |
Intraoral - complete series of radiographic images |
1,197 |
1,197 |
$42K |
| D0274 |
Bitewings - four radiographic images |
2,173 |
2,173 |
$37K |
| D0220 |
Intraoral - periapical first radiographic image |
2,572 |
2,570 |
$22K |
| D1120 |
Prophylaxis - child |
735 |
735 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,795 |
1,795 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,335 |
2,335 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
66 |
51 |
$4K |
| D9110 |
|
13 |
12 |
$155.22 |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$141.62 |