| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,430 |
2,347 |
$102K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,274 |
3,176 |
$87K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,668 |
832 |
$66K |
| D0274 |
Bitewings - four radiographic images |
1,850 |
1,780 |
$42K |
| D0210 |
Intraoral - complete series of radiographic images |
593 |
590 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
643 |
425 |
$32K |
| D0330 |
Panoramic radiographic image |
616 |
593 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
429 |
408 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
143 |
111 |
$8K |
| D2335 |
|
74 |
53 |
$5K |
| D2332 |
|
38 |
25 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
118 |
118 |
$2K |
| D1120 |
Prophylaxis - child |
25 |
25 |
$995.67 |
| D2394 |
|
12 |
12 |
$842.88 |
| D0220 |
Intraoral - periapical first radiographic image |
99 |
92 |
$569.69 |
| D0120 |
Periodic oral evaluation - established patient |
13 |
13 |
$357.50 |