| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,647 |
1,548 |
$35K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,008 |
463 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,273 |
1,216 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
534 |
289 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
723 |
684 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
1,074 |
1,007 |
$17K |
| D1206 |
Topical application of fluoride varnish |
709 |
679 |
$13K |
| D1120 |
Prophylaxis - child |
630 |
613 |
$12K |
| D0274 |
Bitewings - four radiographic images |
670 |
640 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
1,366 |
1,276 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,086 |
1,004 |
$3K |
| D0330 |
Panoramic radiographic image |
176 |
176 |
$3K |
| D1351 |
Sealant - per tooth |
74 |
12 |
$420.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$275.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
65 |
65 |
$125.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$40.00 |