| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1354 |
|
6,585 |
943 |
$300K |
| D1355 |
|
3,182 |
583 |
$233K |
| D1110 |
Prophylaxis - adult |
3,305 |
3,122 |
$169K |
| D0274 |
Bitewings - four radiographic images |
2,576 |
2,409 |
$89K |
| D0120 |
Periodic oral evaluation - established patient |
3,630 |
3,459 |
$88K |
| D0210 |
Intraoral - complete series of radiographic images |
1,570 |
1,440 |
$70K |
| D1206 |
Topical application of fluoride varnish |
2,189 |
2,110 |
$46K |
| D0140 |
Limited oral evaluation - problem focused |
1,179 |
1,077 |
$46K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
460 |
307 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
891 |
838 |
$32K |
| D1120 |
Prophylaxis - child |
604 |
594 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,309 |
817 |
$11K |
| D1351 |
Sealant - per tooth |
381 |
66 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
377 |
316 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
29 |
14 |
$3K |
| D2940 |
|
32 |
26 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
13 |
12 |
$771.45 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$322.53 |