| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,039 |
1,027 |
$51K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,107 |
2,094 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
1,978 |
1,963 |
$41K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
398 |
263 |
$39K |
| D1120 |
Prophylaxis - child |
957 |
949 |
$34K |
| D9630 |
|
1,290 |
1,267 |
$27K |
| D0210 |
Intraoral - complete series of radiographic images |
423 |
350 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
734 |
685 |
$23K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
126 |
96 |
$18K |
| D0274 |
Bitewings - four radiographic images |
587 |
579 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
577 |
508 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
121 |
73 |
$9K |
| D9920 |
|
98 |
92 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
740 |
653 |
$8K |
| D4342 |
|
79 |
27 |
$4K |
| D2394 |
|
19 |
13 |
$3K |
| D0272 |
Bitewings - two radiographic images |
95 |
95 |
$2K |
| D1351 |
Sealant - per tooth |
45 |
14 |
$1K |
| D3120 |
|
25 |
15 |
$598.25 |