| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,684 |
1,193 |
$78K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
805 |
325 |
$56K |
| D0120 |
Periodic oral evaluation - established patient |
2,135 |
1,694 |
$46K |
| D0274 |
Bitewings - four radiographic images |
881 |
660 |
$28K |
| D0140 |
Limited oral evaluation - problem focused |
534 |
384 |
$20K |
| D1120 |
Prophylaxis - child |
612 |
439 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
432 |
316 |
$16K |
| D1206 |
Topical application of fluoride varnish |
682 |
484 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
827 |
667 |
$13K |
| D1351 |
Sealant - per tooth |
315 |
46 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
114 |
63 |
$6K |
| D0330 |
Panoramic radiographic image |
68 |
51 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
12 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
18 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
75 |
65 |
$869.63 |