| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
546 |
539 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
201 |
85 |
$24K |
| D0140 |
Limited oral evaluation - problem focused |
474 |
436 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
360 |
353 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
611 |
591 |
$17K |
| D0274 |
Bitewings - four radiographic images |
654 |
638 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
576 |
556 |
$13K |
| D1120 |
Prophylaxis - child |
292 |
278 |
$12K |
| D0330 |
Panoramic radiographic image |
258 |
249 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
965 |
913 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
780 |
754 |
$7K |
| D1351 |
Sealant - per tooth |
168 |
39 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
12 |
$2K |
| D1330 |
|
168 |
164 |
$986.40 |
| D0272 |
Bitewings - two radiographic images |
17 |
17 |
$255.00 |