| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,249 |
2,249 |
$121K |
| D0120 |
Periodic oral evaluation - established patient |
2,797 |
2,792 |
$75K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
688 |
530 |
$59K |
| D0330 |
Panoramic radiographic image |
670 |
669 |
$25K |
| D0272 |
Bitewings - two radiographic images |
1,461 |
1,461 |
$23K |
| D0274 |
Bitewings - four radiographic images |
529 |
528 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
151 |
123 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
96 |
83 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
212 |
212 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
400 |
398 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
144 |
140 |
$2K |
| D1120 |
Prophylaxis - child |
26 |
26 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$21.62 |