| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,124 |
3,042 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
2,338 |
2,271 |
$53K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,067 |
460 |
$41K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,727 |
1,677 |
$34K |
| D2750 |
|
130 |
87 |
$32K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,927 |
2,797 |
$24K |
| D1120 |
Prophylaxis - child |
675 |
655 |
$11K |
| D0330 |
Panoramic radiographic image |
841 |
813 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
3,108 |
2,991 |
$11K |
| D0191 |
|
597 |
505 |
$9K |
| D0274 |
Bitewings - four radiographic images |
925 |
897 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
899 |
876 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
117 |
68 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
92 |
48 |
$3K |
| D0272 |
Bitewings - two radiographic images |
782 |
771 |
$3K |
| D1351 |
Sealant - per tooth |
286 |
37 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
66 |
66 |
$2K |