| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,450 |
2,420 |
$155K |
| D0120 |
Periodic oral evaluation - established patient |
3,170 |
3,124 |
$97K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
552 |
319 |
$72K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,466 |
2,411 |
$56K |
| D1120 |
Prophylaxis - child |
1,243 |
1,220 |
$55K |
| D1351 |
Sealant - per tooth |
1,308 |
304 |
$43K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
219 |
144 |
$37K |
| D0274 |
Bitewings - four radiographic images |
1,454 |
1,433 |
$34K |
| D1206 |
Topical application of fluoride varnish |
1,183 |
1,183 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
412 |
401 |
$22K |
| D0330 |
Panoramic radiographic image |
475 |
473 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
248 |
240 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
113 |
67 |
$11K |
| D1330 |
|
1,386 |
1,363 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
411 |
383 |
$4K |
| D0272 |
Bitewings - two radiographic images |
36 |
32 |
$501.15 |