| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
732 |
701 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
184 |
85 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
622 |
607 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
736 |
716 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
301 |
288 |
$14K |
| D1120 |
Prophylaxis - child |
232 |
232 |
$10K |
| D1206 |
Topical application of fluoride varnish |
345 |
345 |
$9K |
| D0274 |
Bitewings - four radiographic images |
338 |
329 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
136 |
131 |
$3K |
| D1351 |
Sealant - per tooth |
74 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
336 |
323 |
$2K |
| D1330 |
|
183 |
183 |
$1K |