| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,566 |
2,467 |
$129K |
| D0274 |
Bitewings - four radiographic images |
2,173 |
2,098 |
$76K |
| D0120 |
Periodic oral evaluation - established patient |
2,720 |
2,642 |
$61K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
534 |
285 |
$40K |
| D0210 |
Intraoral - complete series of radiographic images |
530 |
511 |
$36K |
| D0140 |
Limited oral evaluation - problem focused |
894 |
866 |
$34K |
| D1208 |
Topical application of fluoride, excluding varnish |
949 |
910 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
635 |
603 |
$25K |
| D1120 |
Prophylaxis - child |
395 |
389 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,152 |
1,108 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
265 |
153 |
$16K |
| D2740 |
Crown - porcelain/ceramic |
17 |
12 |
$12K |
| D1351 |
Sealant - per tooth |
51 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
75 |
36 |
$848.00 |
| D0272 |
Bitewings - two radiographic images |
13 |
12 |
$360.00 |