| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,481 |
1,451 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,049 |
1,039 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
477 |
288 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
984 |
959 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
551 |
546 |
$11K |
| D0274 |
Bitewings - four radiographic images |
941 |
918 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
1,749 |
1,659 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
447 |
427 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
146 |
93 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,149 |
1,048 |
$3K |
| D0330 |
Panoramic radiographic image |
102 |
102 |
$3K |
| D1351 |
Sealant - per tooth |
132 |
14 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
34 |
24 |
$656.00 |
| D1120 |
Prophylaxis - child |
26 |
26 |
$307.00 |
| D1206 |
Topical application of fluoride varnish |
16 |
16 |
$114.00 |