| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,899 |
1,890 |
$82K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,015 |
584 |
$69K |
| D0120 |
Periodic oral evaluation - established patient |
2,177 |
2,168 |
$55K |
| D1206 |
Topical application of fluoride varnish |
1,556 |
1,552 |
$45K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
513 |
299 |
$28K |
| D0210 |
Intraoral - complete series of radiographic images |
445 |
444 |
$20K |
| D0274 |
Bitewings - four radiographic images |
1,320 |
1,309 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
580 |
575 |
$12K |
| D1120 |
Prophylaxis - child |
410 |
409 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
1,923 |
1,906 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
114 |
85 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,632 |
1,613 |
$8K |
| D1351 |
Sealant - per tooth |
288 |
56 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
186 |
185 |
$5K |
| D0330 |
Panoramic radiographic image |
105 |
105 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
54 |
52 |
$2K |
| D0272 |
Bitewings - two radiographic images |
66 |
66 |
$528.00 |