| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,639 |
1,616 |
$55K |
| D0210 |
Intraoral - complete series of radiographic images |
463 |
463 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
1,497 |
1,497 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
414 |
268 |
$22K |
| D0274 |
Bitewings - four radiographic images |
930 |
905 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
304 |
206 |
$15K |
| D2931 |
|
116 |
91 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
563 |
551 |
$8K |
| D1120 |
Prophylaxis - child |
441 |
431 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
298 |
298 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
13 |
$1K |
| D1351 |
Sealant - per tooth |
57 |
13 |
$990.00 |
| D0272 |
Bitewings - two radiographic images |
100 |
95 |
$970.00 |
| D0140 |
Limited oral evaluation - problem focused |
27 |
27 |
$609.66 |
| D0220 |
Intraoral - periapical first radiographic image |
84 |
84 |
$390.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
78 |
78 |
$370.00 |