| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,443 |
2,391 |
$156K |
| D0120 |
Periodic oral evaluation - established patient |
4,102 |
4,019 |
$124K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
982 |
515 |
$123K |
| D1120 |
Prophylaxis - child |
2,525 |
2,484 |
$110K |
| D0274 |
Bitewings - four radiographic images |
2,376 |
2,320 |
$68K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,755 |
2,706 |
$65K |
| D0220 |
Intraoral - periapical first radiographic image |
4,232 |
4,119 |
$51K |
| D1206 |
Topical application of fluoride varnish |
1,845 |
1,812 |
$47K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
457 |
277 |
$44K |
| D8670 |
Periodic orthodontic treatment visit |
651 |
641 |
$37K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
574 |
566 |
$33K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,821 |
3,722 |
$33K |
| D0272 |
Bitewings - two radiographic images |
973 |
966 |
$20K |
| D1351 |
Sealant - per tooth |
412 |
74 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
272 |
270 |
$12K |
| D1330 |
|
995 |
983 |
$6K |
| D8660 |
|
12 |
12 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
16 |
16 |
$912.00 |