| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
10,089 |
10,085 |
$367K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
5,342 |
2,628 |
$348K |
| D0120 |
Periodic oral evaluation - established patient |
9,740 |
9,735 |
$207K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,323 |
1,862 |
$150K |
| D0274 |
Bitewings - four radiographic images |
6,145 |
6,144 |
$125K |
| D1120 |
Prophylaxis - child |
2,248 |
2,247 |
$92K |
| D0330 |
Panoramic radiographic image |
3,400 |
3,400 |
$88K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,237 |
810 |
$88K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,039 |
3,039 |
$70K |
| D0220 |
Intraoral - periapical first radiographic image |
7,698 |
7,691 |
$69K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,075 |
7,069 |
$35K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,301 |
2,300 |
$32K |
| D0210 |
Intraoral - complete series of radiographic images |
414 |
414 |
$15K |
| D2332 |
|
138 |
76 |
$10K |
| D2331 |
|
156 |
63 |
$7K |
| D3320 |
|
26 |
25 |
$5K |
| D4341 |
|
71 |
52 |
$5K |
| D2330 |
|
143 |
77 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
232 |
232 |
$2K |
| D1206 |
Topical application of fluoride varnish |
76 |
76 |
$2K |
| D2394 |
|
25 |
12 |
$2K |
| D2954 |
|
12 |
12 |
$2K |