| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,477 |
2,477 |
$84K |
| D0120 |
Periodic oral evaluation - established patient |
2,530 |
2,530 |
$50K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
834 |
429 |
$35K |
| D0210 |
Intraoral - complete series of radiographic images |
1,935 |
1,935 |
$35K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,827 |
1,825 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
348 |
272 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
1,986 |
1,983 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
666 |
666 |
$13K |
| D1120 |
Prophylaxis - child |
279 |
279 |
$9K |
| D0274 |
Bitewings - four radiographic images |
372 |
372 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
236 |
236 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$679.20 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$333.15 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$141.80 |
| D9986 |
|
15 |
13 |
$0.00 |
| D1330 |
|
46 |
46 |
$0.00 |