| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,247 |
1,239 |
$44K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
581 |
329 |
$35K |
| D0274 |
Bitewings - four radiographic images |
1,063 |
1,055 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
586 |
311 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
1,147 |
1,141 |
$26K |
| D1351 |
Sealant - per tooth |
714 |
123 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
612 |
605 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,437 |
1,416 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,262 |
1,246 |
$10K |
| D1120 |
Prophylaxis - child |
329 |
327 |
$10K |
| D1206 |
Topical application of fluoride varnish |
562 |
558 |
$9K |
| D0330 |
Panoramic radiographic image |
191 |
187 |
$7K |
| D0272 |
Bitewings - two radiographic images |
346 |
344 |
$5K |
| D9110 |
|
63 |
62 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
25 |
25 |
$2K |
| D1999 |
|
13 |
13 |
$0.00 |