| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
940 |
920 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
446 |
313 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
937 |
915 |
$18K |
| D1206 |
Topical application of fluoride varnish |
1,230 |
1,203 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
340 |
335 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
747 |
731 |
$14K |
| D1120 |
Prophylaxis - child |
585 |
570 |
$12K |
| D1351 |
Sealant - per tooth |
697 |
115 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
651 |
629 |
$9K |
| D0330 |
Panoramic radiographic image |
219 |
216 |
$8K |
| D0274 |
Bitewings - four radiographic images |
299 |
288 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
491 |
476 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
53 |
34 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
32 |
25 |
$2K |
| D0272 |
Bitewings - two radiographic images |
105 |
103 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
33 |
28 |
$167.56 |