| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,910 |
1,879 |
$119K |
| D0120 |
Periodic oral evaluation - established patient |
3,515 |
3,462 |
$106K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
748 |
392 |
$95K |
| D1120 |
Prophylaxis - child |
1,955 |
1,926 |
$86K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,586 |
3,537 |
$83K |
| D1351 |
Sealant - per tooth |
1,500 |
311 |
$50K |
| D0274 |
Bitewings - four radiographic images |
1,747 |
1,716 |
$40K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
396 |
178 |
$40K |
| D0330 |
Panoramic radiographic image |
835 |
819 |
$37K |
| D0140 |
Limited oral evaluation - problem focused |
523 |
500 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
360 |
350 |
$19K |
| D0272 |
Bitewings - two radiographic images |
989 |
979 |
$15K |
| D1330 |
|
1,530 |
1,503 |
$9K |
| D8670 |
Periodic orthodontic treatment visit |
118 |
118 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
777 |
748 |
$9K |
| D2750 |
|
15 |
14 |
$7K |
| D4341 |
|
63 |
24 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
30 |
15 |
$5K |
| D2330 |
|
34 |
12 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
295 |
295 |
$2K |