| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
5,905 |
5,901 |
$193K |
| D0120 |
Periodic oral evaluation - established patient |
7,764 |
7,757 |
$139K |
| D0274 |
Bitewings - four radiographic images |
4,423 |
4,420 |
$75K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,330 |
899 |
$68K |
| D1120 |
Prophylaxis - child |
1,688 |
1,686 |
$47K |
| D0220 |
Intraoral - periapical first radiographic image |
4,514 |
4,487 |
$38K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,778 |
2,776 |
$26K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,942 |
3,932 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
356 |
263 |
$13K |
| D1351 |
Sealant - per tooth |
283 |
110 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
144 |
120 |
$8K |
| D2330 |
|
147 |
106 |
$5K |
| D1206 |
Topical application of fluoride varnish |
44 |
44 |
$1K |
| D2331 |
|
15 |
14 |
$650.54 |
| D0601 |
|
50 |
50 |
$25.00 |
| D1999 |
|
16 |
16 |
$0.00 |