| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,929 |
2,927 |
$121K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,222 |
576 |
$73K |
| D0274 |
Bitewings - four radiographic images |
2,648 |
2,648 |
$57K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,000 |
1,999 |
$43K |
| D0220 |
Intraoral - periapical first radiographic image |
3,167 |
3,139 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
1,416 |
1,416 |
$32K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
718 |
425 |
$27K |
| D2750 |
|
66 |
48 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,897 |
2,888 |
$19K |
| D0210 |
Intraoral - complete series of radiographic images |
1,166 |
1,155 |
$19K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
226 |
161 |
$15K |
| D1120 |
Prophylaxis - child |
382 |
382 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
541 |
510 |
$6K |
| D1351 |
Sealant - per tooth |
128 |
44 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
443 |
443 |
$5K |
| D4341 |
|
127 |
46 |
$4K |
| D9944 |
|
16 |
16 |
$2K |
| D0330 |
Panoramic radiographic image |
65 |
65 |
$2K |