| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,178 |
2,178 |
$138K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,124 |
775 |
$108K |
| D0120 |
Periodic oral evaluation - established patient |
1,830 |
1,830 |
$58K |
| D0330 |
Panoramic radiographic image |
1,039 |
1,039 |
$41K |
| D0274 |
Bitewings - four radiographic images |
1,493 |
1,493 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,059 |
1,059 |
$35K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
421 |
314 |
$27K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
185 |
149 |
$22K |
| D2331 |
|
71 |
52 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
633 |
629 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
133 |
133 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
616 |
364 |
$2K |
| D1120 |
Prophylaxis - child |
24 |
24 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
51 |
50 |
$834.11 |