| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,870 |
3,708 |
$133K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,464 |
997 |
$93K |
| D0120 |
Periodic oral evaluation - established patient |
5,396 |
5,167 |
$92K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,175 |
4,027 |
$61K |
| D0274 |
Bitewings - four radiographic images |
2,275 |
2,190 |
$49K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
898 |
576 |
$41K |
| D1120 |
Prophylaxis - child |
974 |
930 |
$25K |
| D0140 |
Limited oral evaluation - problem focused |
934 |
898 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
2,218 |
2,090 |
$21K |
| D0330 |
Panoramic radiographic image |
140 |
131 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
48 |
45 |
$3K |
| D0272 |
Bitewings - two radiographic images |
90 |
89 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
18 |
17 |
$892.87 |
| D0230 |
Intraoral - periapical each additional radiographic image |
59 |
57 |
$467.48 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$171.96 |