| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,408 |
2,408 |
$86K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,299 |
588 |
$68K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,261 |
2,261 |
$49K |
| D0210 |
Intraoral - complete series of radiographic images |
1,267 |
1,267 |
$45K |
| D0274 |
Bitewings - four radiographic images |
1,735 |
1,735 |
$34K |
| D1120 |
Prophylaxis - child |
687 |
687 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
1,894 |
1,892 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
866 |
866 |
$18K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
137 |
94 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,845 |
1,840 |
$9K |
| D1351 |
Sealant - per tooth |
251 |
59 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
720 |
720 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
243 |
114 |
$8K |
| D4341 |
|
75 |
25 |
$2K |
| D2332 |
|
18 |
13 |
$1K |