| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,150 |
2,141 |
$101K |
| D0120 |
Periodic oral evaluation - established patient |
2,395 |
2,387 |
$67K |
| D2335 |
|
644 |
252 |
$63K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,042 |
2,036 |
$53K |
| D4355 |
|
395 |
392 |
$53K |
| D1120 |
Prophylaxis - child |
910 |
910 |
$46K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
446 |
263 |
$35K |
| D0140 |
Limited oral evaluation - problem focused |
618 |
614 |
$31K |
| D2394 |
|
278 |
170 |
$25K |
| D2332 |
|
375 |
180 |
$24K |
| D2330 |
|
223 |
87 |
$13K |
| D0330 |
Panoramic radiographic image |
299 |
297 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
351 |
350 |
$9K |
| D0274 |
Bitewings - four radiographic images |
440 |
436 |
$6K |
| D1351 |
Sealant - per tooth |
205 |
28 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
49 |
28 |
$3K |
| D0272 |
Bitewings - two radiographic images |
282 |
282 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
169 |
144 |
$821.25 |
| D0230 |
Intraoral - periapical each additional radiographic image |
69 |
68 |
$231.00 |