| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
1,737 |
1,628 |
$164K |
| D0120 |
Periodic oral evaluation - established patient |
1,290 |
1,249 |
$141K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
533 |
508 |
$49K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
642 |
406 |
$44K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
442 |
280 |
$26K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
16 |
$3K |
| D1110 |
Prophylaxis - adult |
866 |
833 |
$134.57 |
| D1120 |
Prophylaxis - child |
1,168 |
1,137 |
$132.78 |
| D1206 |
Topical application of fluoride varnish |
2,173 |
2,090 |
$98.58 |
| D0274 |
Bitewings - four radiographic images |
755 |
726 |
$68.35 |
| D0220 |
Intraoral - periapical first radiographic image |
1,015 |
944 |
$52.55 |
| D0272 |
Bitewings - two radiographic images |
138 |
128 |
$0.00 |
| D1351 |
Sealant - per tooth |
680 |
227 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
312 |
211 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
145 |
145 |
$0.00 |