| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,134 |
1,121 |
$68K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
367 |
273 |
$49K |
| D1206 |
Topical application of fluoride varnish |
1,695 |
1,672 |
$43K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
222 |
160 |
$37K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
649 |
643 |
$34K |
| D0210 |
Intraoral - complete series of radiographic images |
581 |
572 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
916 |
909 |
$26K |
| D1351 |
Sealant - per tooth |
618 |
95 |
$22K |
| D1120 |
Prophylaxis - child |
353 |
347 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
282 |
270 |
$12K |
| D3120 |
|
251 |
190 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
783 |
751 |
$8K |
| D2332 |
|
42 |
25 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
574 |
556 |
$6K |
| D9910 |
|
503 |
491 |
$5K |
| D4341 |
|
45 |
13 |
$4K |
| D2335 |
|
21 |
12 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
27 |
25 |
$3K |
| D1330 |
|
421 |
420 |
$3K |
| D0274 |
Bitewings - four radiographic images |
98 |
98 |
$2K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$180.00 |