| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
624 |
562 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
264 |
131 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
1,213 |
1,090 |
$18K |
| D1120 |
Prophylaxis - child |
385 |
358 |
$9K |
| D1206 |
Topical application of fluoride varnish |
525 |
473 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
325 |
306 |
$5K |
| D0274 |
Bitewings - four radiographic images |
227 |
195 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
82 |
45 |
$4K |
| D1351 |
Sealant - per tooth |
195 |
37 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
83 |
68 |
$2K |
| D0272 |
Bitewings - two radiographic images |
104 |
96 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
68 |
62 |
$622.37 |
| D0330 |
Panoramic radiographic image |
15 |
13 |
$540.30 |
| D0230 |
Intraoral - periapical each additional radiographic image |
73 |
43 |
$482.52 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
20 |
14 |
$376.05 |