| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,544 |
1,339 |
$74K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
726 |
368 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
1,621 |
1,424 |
$37K |
| D0274 |
Bitewings - four radiographic images |
766 |
674 |
$25K |
| D0210 |
Intraoral - complete series of radiographic images |
750 |
502 |
$23K |
| D1206 |
Topical application of fluoride varnish |
788 |
697 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
418 |
351 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,392 |
651 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
115 |
68 |
$12K |
| D1120 |
Prophylaxis - child |
383 |
340 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
952 |
776 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
104 |
65 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
164 |
142 |
$6K |
| D1351 |
Sealant - per tooth |
272 |
54 |
$6K |
| D0330 |
Panoramic radiographic image |
69 |
65 |
$3K |
| D0272 |
Bitewings - two radiographic images |
31 |
26 |
$620.25 |