| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,463 |
2,253 |
$123K |
| D0210 |
Intraoral - complete series of radiographic images |
1,319 |
1,173 |
$87K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,059 |
531 |
$87K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,917 |
1,767 |
$72K |
| D0274 |
Bitewings - four radiographic images |
1,556 |
1,450 |
$51K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
725 |
315 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
1,667 |
1,521 |
$39K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,082 |
1,912 |
$29K |
| D0220 |
Intraoral - periapical first radiographic image |
2,027 |
1,833 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
820 |
756 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
82 |
52 |
$8K |
| D1120 |
Prophylaxis - child |
236 |
226 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
178 |
161 |
$7K |
| D1351 |
Sealant - per tooth |
201 |
30 |
$6K |
| D1206 |
Topical application of fluoride varnish |
78 |
76 |
$2K |
| D0330 |
Panoramic radiographic image |
33 |
27 |
$574.24 |