| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,589 |
3,320 |
$164K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,567 |
1,008 |
$107K |
| D0120 |
Periodic oral evaluation - established patient |
4,437 |
4,145 |
$97K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
870 |
538 |
$47K |
| D0140 |
Limited oral evaluation - problem focused |
1,366 |
1,176 |
$45K |
| D0274 |
Bitewings - four radiographic images |
976 |
900 |
$34K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,008 |
942 |
$21K |
| D0272 |
Bitewings - two radiographic images |
778 |
734 |
$17K |
| D0330 |
Panoramic radiographic image |
235 |
213 |
$15K |
| D1120 |
Prophylaxis - child |
236 |
227 |
$8K |
| D2335 |
|
46 |
26 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
480 |
429 |
$5K |
| D1351 |
Sealant - per tooth |
56 |
12 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
25 |
21 |
$852.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
14 |
$259.50 |