| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
728 |
679 |
$38K |
| D0274 |
Bitewings - four radiographic images |
658 |
612 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
991 |
897 |
$23K |
| D1120 |
Prophylaxis - child |
301 |
291 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
387 |
375 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
642 |
608 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
216 |
204 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
123 |
68 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
216 |
161 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
308 |
293 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
47 |
37 |
$2K |
| D1351 |
Sealant - per tooth |
44 |
12 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
12 |
$1K |