| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,720 |
2,685 |
$99K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,149 |
669 |
$84K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,603 |
2,580 |
$48K |
| D0120 |
Periodic oral evaluation - established patient |
2,985 |
2,951 |
$48K |
| D0274 |
Bitewings - four radiographic images |
1,872 |
1,848 |
$39K |
| D1120 |
Prophylaxis - child |
746 |
741 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
807 |
749 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,919 |
1,791 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
308 |
208 |
$13K |
| D9910 |
|
388 |
385 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,422 |
1,159 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
391 |
360 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
45 |
36 |
$5K |
| D0330 |
Panoramic radiographic image |
91 |
91 |
$2K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$241.80 |