| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,028 |
1,028 |
$45K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
361 |
335 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
1,348 |
1,348 |
$29K |
| D0274 |
Bitewings - four radiographic images |
1,079 |
1,079 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
446 |
367 |
$22K |
| D1120 |
Prophylaxis - child |
591 |
591 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,790 |
1,780 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,779 |
1,772 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
945 |
945 |
$11K |
| D1351 |
Sealant - per tooth |
66 |
66 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
285 |
285 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
440 |
437 |
$1K |
| D9990 |
|
61 |
54 |
$671.00 |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$201.18 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$132.79 |