| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,811 |
1,781 |
$91K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
929 |
425 |
$59K |
| D0120 |
Periodic oral evaluation - established patient |
1,550 |
1,519 |
$46K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
907 |
896 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
651 |
343 |
$34K |
| D0274 |
Bitewings - four radiographic images |
2,024 |
1,980 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
2,418 |
2,315 |
$11K |
| D2332 |
|
154 |
51 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,715 |
2,212 |
$6K |
| D9999 |
Unspecified adjunctive procedure, by report |
28 |
28 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
141 |
141 |
$3K |
| D1120 |
Prophylaxis - child |
40 |
40 |
$855.00 |
| D1999 |
|
185 |
172 |
$430.00 |
| D9430 |
|
290 |
235 |
$330.00 |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$132.00 |