| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,636 |
3,634 |
$131K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
877 |
531 |
$51K |
| D0274 |
Bitewings - four radiographic images |
2,643 |
2,641 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
2,514 |
2,514 |
$50K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,723 |
1,721 |
$36K |
| D0220 |
Intraoral - periapical first radiographic image |
3,662 |
3,621 |
$33K |
| D0330 |
Panoramic radiographic image |
1,108 |
1,107 |
$28K |
| D0210 |
Intraoral - complete series of radiographic images |
1,391 |
1,373 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,038 |
3,017 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
928 |
928 |
$10K |
| D2750 |
|
12 |
12 |
$6K |
| D2752 |
|
18 |
14 |
$6K |
| D1120 |
Prophylaxis - child |
63 |
63 |
$2K |
| D2954 |
|
19 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
60 |
59 |
$561.91 |
| D9110 |
|
26 |
26 |
$381.12 |
| D0160 |
|
12 |
12 |
$151.60 |