| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,977 |
1,977 |
$126K |
| D0120 |
Periodic oral evaluation - established patient |
2,138 |
2,137 |
$70K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
674 |
495 |
$66K |
| D1206 |
Topical application of fluoride varnish |
1,124 |
1,124 |
$42K |
| D0274 |
Bitewings - four radiographic images |
1,128 |
1,127 |
$41K |
| D1120 |
Prophylaxis - child |
782 |
782 |
$41K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
217 |
178 |
$27K |
| D0330 |
Panoramic radiographic image |
363 |
362 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
812 |
812 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
247 |
247 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
90 |
64 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
160 |
160 |
$2K |
| D2394 |
|
16 |
13 |
$2K |
| D0272 |
Bitewings - two radiographic images |
98 |
98 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
86 |
86 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
15 |
15 |
$172.00 |