| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,186 |
1,185 |
$61K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
435 |
306 |
$56K |
| D0120 |
Periodic oral evaluation - established patient |
1,587 |
1,585 |
$42K |
| D0274 |
Bitewings - four radiographic images |
763 |
762 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
1,444 |
1,383 |
$23K |
| D1120 |
Prophylaxis - child |
489 |
488 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
745 |
744 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
372 |
358 |
$16K |
| D2950 |
|
61 |
51 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,271 |
996 |
$11K |
| D1351 |
Sealant - per tooth |
244 |
42 |
$8K |
| D0330 |
Panoramic radiographic image |
107 |
107 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
80 |
80 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
13 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
19 |
19 |
$1K |