| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
6,541 |
6,536 |
$262K |
| D0120 |
Periodic oral evaluation - established patient |
7,946 |
7,939 |
$169K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,350 |
1,738 |
$128K |
| D0330 |
Panoramic radiographic image |
2,913 |
2,911 |
$84K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
971 |
832 |
$61K |
| D1120 |
Prophylaxis - child |
951 |
951 |
$36K |
| D0274 |
Bitewings - four radiographic images |
1,611 |
1,611 |
$36K |
| D1208 |
Topical application of fluoride, excluding varnish |
967 |
967 |
$12K |
| D0272 |
Bitewings - two radiographic images |
904 |
904 |
$11K |
| D9110 |
|
552 |
548 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
91 |
84 |
$6K |
| D2394 |
|
71 |
65 |
$6K |
| D9945 |
|
24 |
24 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
320 |
317 |
$3K |
| D2335 |
|
20 |
14 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
46 |
42 |
$323.90 |