| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,977 |
1,971 |
$88K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
633 |
431 |
$64K |
| D0120 |
Periodic oral evaluation - established patient |
1,966 |
1,957 |
$47K |
| D0274 |
Bitewings - four radiographic images |
1,053 |
1,050 |
$28K |
| D0330 |
Panoramic radiographic image |
327 |
326 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
207 |
206 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
104 |
72 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
458 |
456 |
$7K |
| D1351 |
Sealant - per tooth |
209 |
29 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
31 |
26 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
93 |
93 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
366 |
202 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
118 |
118 |
$3K |
| D1120 |
Prophylaxis - child |
26 |
26 |
$1K |