| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,996 |
2,994 |
$104K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,512 |
718 |
$84K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,014 |
758 |
$68K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,242 |
2,242 |
$46K |
| D0210 |
Intraoral - complete series of radiographic images |
1,598 |
1,584 |
$40K |
| D0274 |
Bitewings - four radiographic images |
2,001 |
2,000 |
$38K |
| D0220 |
Intraoral - periapical first radiographic image |
3,506 |
3,475 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,545 |
1,544 |
$31K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,634 |
2,633 |
$22K |
| D1120 |
Prophylaxis - child |
492 |
492 |
$16K |
| D2954 |
|
131 |
95 |
$12K |
| D1351 |
Sealant - per tooth |
313 |
68 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
930 |
917 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
763 |
763 |
$9K |
| D0270 |
|
495 |
495 |
$5K |
| D2750 |
|
15 |
14 |
$4K |
| D0272 |
Bitewings - two radiographic images |
118 |
118 |
$1K |
| D9944 |
|
13 |
13 |
$1K |