| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,817 |
1,336 |
$49K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
780 |
309 |
$38K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
626 |
203 |
$33K |
| D0210 |
Intraoral - complete series of radiographic images |
1,143 |
706 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,198 |
916 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
1,295 |
984 |
$20K |
| D1120 |
Prophylaxis - child |
417 |
408 |
$13K |
| D0274 |
Bitewings - four radiographic images |
785 |
737 |
$12K |
| D2394 |
|
105 |
47 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
910 |
847 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
894 |
864 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
280 |
280 |
$4K |
| D1206 |
Topical application of fluoride varnish |
240 |
224 |
$2K |
| D1351 |
Sealant - per tooth |
43 |
13 |
$1K |
| D1999 |
|
381 |
264 |
$0.00 |