| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,873 |
2,721 |
$136K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,424 |
713 |
$120K |
| D0120 |
Periodic oral evaluation - established patient |
2,794 |
2,667 |
$76K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
881 |
399 |
$59K |
| D0210 |
Intraoral - complete series of radiographic images |
720 |
655 |
$40K |
| D0140 |
Limited oral evaluation - problem focused |
960 |
953 |
$40K |
| D0274 |
Bitewings - four radiographic images |
661 |
644 |
$20K |
| D0272 |
Bitewings - two radiographic images |
694 |
665 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,388 |
1,224 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
513 |
499 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
191 |
172 |
$7K |
| D1120 |
Prophylaxis - child |
92 |
84 |
$3K |
| D1351 |
Sealant - per tooth |
80 |
24 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
14 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
67 |
53 |
$555.83 |