| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,594 |
1,498 |
$57K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
540 |
281 |
$52K |
| D0120 |
Periodic oral evaluation - established patient |
2,036 |
1,963 |
$44K |
| D1120 |
Prophylaxis - child |
744 |
735 |
$31K |
| D0330 |
Panoramic radiographic image |
833 |
780 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
854 |
801 |
$26K |
| D1208 |
Topical application of fluoride, excluding varnish |
870 |
859 |
$20K |
| D0274 |
Bitewings - four radiographic images |
1,196 |
1,134 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
551 |
509 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
125 |
51 |
$10K |
| D1351 |
Sealant - per tooth |
185 |
39 |
$6K |
| D1206 |
Topical application of fluoride varnish |
166 |
166 |
$4K |
| D1330 |
|
396 |
388 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
22 |
14 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
25 |
$306.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$180.00 |