| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,411 |
4,411 |
$233K |
| D0120 |
Periodic oral evaluation - established patient |
6,550 |
6,550 |
$176K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
736 |
437 |
$63K |
| D0210 |
Intraoral - complete series of radiographic images |
1,233 |
1,233 |
$60K |
| D1120 |
Prophylaxis - child |
1,193 |
1,193 |
$51K |
| D0274 |
Bitewings - four radiographic images |
1,373 |
1,373 |
$36K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,956 |
1,956 |
$27K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
216 |
131 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
86 |
69 |
$6K |
| D0330 |
Panoramic radiographic image |
137 |
137 |
$5K |
| D1351 |
Sealant - per tooth |
32 |
26 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
59 |
58 |
$555.78 |
| D0140 |
Limited oral evaluation - problem focused |
17 |
16 |
$238.00 |