| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
894 |
888 |
$71K |
| D0120 |
Periodic oral evaluation - established patient |
1,279 |
1,265 |
$52K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
731 |
458 |
$47K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,403 |
2,118 |
$31K |
| D0274 |
Bitewings - four radiographic images |
1,227 |
1,226 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
457 |
266 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
402 |
400 |
$23K |
| D1120 |
Prophylaxis - child |
749 |
741 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,768 |
1,756 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
732 |
697 |
$8K |
| D0350 |
|
625 |
369 |
$6K |
| D9430 |
|
107 |
103 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
12 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
27 |
27 |
$1K |