| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,989 |
4,988 |
$196K |
| D0120 |
Periodic oral evaluation - established patient |
5,353 |
5,349 |
$113K |
| D0210 |
Intraoral - complete series of radiographic images |
2,136 |
2,129 |
$85K |
| D0274 |
Bitewings - four radiographic images |
2,889 |
2,889 |
$60K |
| D2750 |
|
55 |
48 |
$31K |
| D0220 |
Intraoral - periapical first radiographic image |
3,648 |
3,631 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,172 |
3,170 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
193 |
167 |
$14K |
| D2954 |
|
84 |
70 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
110 |
100 |
$10K |
| D1120 |
Prophylaxis - child |
215 |
215 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
570 |
564 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
128 |
128 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
12 |
12 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
97 |
97 |
$711.20 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$319.10 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$126.97 |