| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
5,229 |
5,220 |
$343K |
| D0120 |
Periodic oral evaluation - established patient |
5,434 |
5,424 |
$183K |
| D0274 |
Bitewings - four radiographic images |
3,527 |
3,514 |
$132K |
| D1206 |
Topical application of fluoride varnish |
3,416 |
3,413 |
$127K |
| D1120 |
Prophylaxis - child |
2,406 |
2,403 |
$126K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
960 |
666 |
$118K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
973 |
647 |
$95K |
| D0330 |
Panoramic radiographic image |
926 |
920 |
$42K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
578 |
369 |
$37K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,127 |
2,125 |
$35K |
| D0220 |
Intraoral - periapical first radiographic image |
1,697 |
1,664 |
$27K |
| D0272 |
Bitewings - two radiographic images |
756 |
755 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
545 |
543 |
$15K |
| D2394 |
|
46 |
40 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
393 |
391 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
530 |
528 |
$6K |
| D1351 |
Sealant - per tooth |
97 |
26 |
$5K |
| D2332 |
|
24 |
13 |
$3K |