| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,375 |
1,375 |
$63K |
| D0120 |
Periodic oral evaluation - established patient |
1,432 |
1,432 |
$33K |
| D0274 |
Bitewings - four radiographic images |
1,389 |
1,389 |
$32K |
| D0220 |
Intraoral - periapical first radiographic image |
1,946 |
1,939 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
275 |
181 |
$17K |
| D1120 |
Prophylaxis - child |
502 |
502 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,802 |
1,801 |
$16K |
| D9990 |
|
604 |
542 |
$13K |
| D1351 |
Sealant - per tooth |
351 |
88 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
424 |
424 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
854 |
854 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
236 |
154 |
$9K |
| D9944 |
|
55 |
55 |
$6K |
| D2332 |
|
31 |
27 |
$2K |
| D2330 |
|
56 |
44 |
$2K |
| D4341 |
|
42 |
14 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
720 |
716 |
$868.93 |
| D0272 |
Bitewings - two radiographic images |
43 |
43 |
$586.75 |