| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,757 |
1,716 |
$97K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
569 |
316 |
$46K |
| D0120 |
Periodic oral evaluation - established patient |
1,508 |
1,488 |
$42K |
| D0140 |
Limited oral evaluation - problem focused |
860 |
809 |
$39K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
389 |
221 |
$27K |
| D0210 |
Intraoral - complete series of radiographic images |
550 |
531 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,039 |
1,014 |
$25K |
| D1206 |
Topical application of fluoride varnish |
745 |
735 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
540 |
524 |
$19K |
| D1120 |
Prophylaxis - child |
380 |
375 |
$19K |
| D2750 |
|
14 |
13 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,607 |
1,499 |
$9K |
| D0274 |
Bitewings - four radiographic images |
608 |
599 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,067 |
1,005 |
$4K |
| D2954 |
|
13 |
13 |
$2K |
| D1351 |
Sealant - per tooth |
70 |
12 |
$2K |
| D0190 |
|
13 |
13 |
$65.00 |
| D1999 |
|
50 |
44 |
$0.00 |