| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,559 |
1,489 |
$64K |
| D0120 |
Periodic oral evaluation - established patient |
1,981 |
1,850 |
$39K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
572 |
298 |
$36K |
| D0274 |
Bitewings - four radiographic images |
1,123 |
1,044 |
$35K |
| D1206 |
Topical application of fluoride varnish |
1,606 |
1,481 |
$23K |
| D1120 |
Prophylaxis - child |
731 |
665 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,304 |
1,200 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
478 |
445 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
838 |
712 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
194 |
161 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
168 |
83 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
24 |
13 |
$2K |
| D1351 |
Sealant - per tooth |
106 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
35 |
30 |
$511.00 |
| D1999 |
|
25 |
18 |
$10.00 |