| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,552 |
2,347 |
$68K |
| D0120 |
Periodic oral evaluation - established patient |
3,285 |
3,006 |
$46K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
841 |
523 |
$46K |
| D0274 |
Bitewings - four radiographic images |
1,324 |
1,227 |
$23K |
| D1206 |
Topical application of fluoride varnish |
1,579 |
1,456 |
$21K |
| D1351 |
Sealant - per tooth |
857 |
87 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,280 |
1,114 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
110 |
82 |
$8K |
| D1120 |
Prophylaxis - child |
399 |
369 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
282 |
252 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
111 |
84 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
73 |
70 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
630 |
519 |
$4K |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$261.27 |