| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,196 |
1,189 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
1,134 |
1,128 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
368 |
161 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
484 |
183 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
424 |
422 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,274 |
1,357 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
1,636 |
1,620 |
$6K |
| D0274 |
Bitewings - four radiographic images |
409 |
402 |
$3K |
| D0272 |
Bitewings - two radiographic images |
400 |
400 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
166 |
166 |
$2K |
| D1120 |
Prophylaxis - child |
102 |
102 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
43 |
43 |
$1K |
| D0330 |
Panoramic radiographic image |
42 |
40 |
$487.25 |