| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,230 |
2,228 |
$123K |
| D0120 |
Periodic oral evaluation - established patient |
2,361 |
2,357 |
$65K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
356 |
255 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
248 |
172 |
$20K |
| D0272 |
Bitewings - two radiographic images |
1,133 |
1,133 |
$18K |
| D1120 |
Prophylaxis - child |
368 |
368 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
521 |
521 |
$15K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
106 |
86 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
495 |
494 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
390 |
383 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
14 |
$2K |
| D2160 |
|
13 |
13 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$862.00 |