| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,406 |
3,338 |
$186K |
| D0120 |
Periodic oral evaluation - established patient |
4,895 |
4,816 |
$122K |
| D1120 |
Prophylaxis - child |
1,834 |
1,815 |
$92K |
| D1206 |
Topical application of fluoride varnish |
2,572 |
2,542 |
$67K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
781 |
564 |
$59K |
| D0274 |
Bitewings - four radiographic images |
1,185 |
1,171 |
$43K |
| D0140 |
Limited oral evaluation - problem focused |
1,051 |
1,000 |
$41K |
| D0330 |
Panoramic radiographic image |
226 |
222 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
237 |
182 |
$15K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
113 |
100 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
633 |
609 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
91 |
87 |
$6K |
| D1351 |
Sealant - per tooth |
146 |
36 |
$5K |
| D0272 |
Bitewings - two radiographic images |
114 |
113 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
27 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
51 |
37 |
$597.00 |