| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,662 |
1,480 |
$70K |
| D1110 |
Prophylaxis - adult |
1,767 |
1,699 |
$62K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,254 |
450 |
$56K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,890 |
1,669 |
$51K |
| D0274 |
Bitewings - four radiographic images |
1,479 |
1,387 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,786 |
1,634 |
$33K |
| D1206 |
Topical application of fluoride varnish |
683 |
683 |
$24K |
| D9110 |
|
428 |
352 |
$17K |
| D1310 |
|
604 |
403 |
$13K |
| D1330 |
|
604 |
403 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
292 |
283 |
$11K |
| D2140 |
|
366 |
150 |
$11K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
235 |
135 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
374 |
347 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
103 |
63 |
$6K |
| D2160 |
|
57 |
39 |
$3K |
| D1351 |
Sealant - per tooth |
107 |
25 |
$2K |
| D0330 |
Panoramic radiographic image |
50 |
42 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
128 |
121 |
$1K |
| D0272 |
Bitewings - two radiographic images |
54 |
45 |
$968.00 |
| D2330 |
|
25 |
12 |
$965.00 |
| D0220 |
Intraoral - periapical first radiographic image |
72 |
69 |
$718.00 |