| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
5,875 |
5,861 |
$126K |
| D0120 |
Periodic oral evaluation - established patient |
5,043 |
5,009 |
$108K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,896 |
1,127 |
$81K |
| D0210 |
Intraoral - complete series of radiographic images |
1,999 |
1,998 |
$62K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,305 |
2,304 |
$48K |
| D2750 |
|
107 |
98 |
$44K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,083 |
608 |
$40K |
| D0274 |
Bitewings - four radiographic images |
3,412 |
3,399 |
$34K |
| D0230 |
Intraoral - periapical each additional radiographic image |
10,698 |
4,648 |
$30K |
| D1120 |
Prophylaxis - child |
1,053 |
1,035 |
$28K |
| D1206 |
Topical application of fluoride varnish |
1,529 |
1,509 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
5,283 |
5,228 |
$22K |
| D1351 |
Sealant - per tooth |
1,167 |
146 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
571 |
564 |
$12K |
| D0272 |
Bitewings - two radiographic images |
1,507 |
1,487 |
$11K |
| D0601 |
|
551 |
547 |
$5K |
| D0330 |
Panoramic radiographic image |
1,062 |
1,057 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
250 |
249 |
$3K |
| D0270 |
|
209 |
209 |
$836.00 |