| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
666 |
634 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
436 |
423 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
687 |
639 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
181 |
121 |
$10K |
| D1120 |
Prophylaxis - child |
440 |
419 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
552 |
519 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
328 |
310 |
$7K |
| D0274 |
Bitewings - four radiographic images |
287 |
271 |
$6K |
| D0330 |
Panoramic radiographic image |
115 |
108 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
55 |
42 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
530 |
500 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
218 |
122 |
$1K |
| D1351 |
Sealant - per tooth |
56 |
13 |
$1K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$115.50 |
| D1999 |
|
21 |
19 |
$0.00 |
| D0190 |
|
26 |
25 |
$0.00 |