| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,145 |
3,134 |
$112K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,242 |
814 |
$61K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
939 |
734 |
$56K |
| D0120 |
Periodic oral evaluation - established patient |
2,601 |
2,592 |
$52K |
| D0330 |
Panoramic radiographic image |
1,088 |
1,083 |
$40K |
| D1351 |
Sealant - per tooth |
1,026 |
191 |
$25K |
| D0272 |
Bitewings - two radiographic images |
1,294 |
1,291 |
$21K |
| D2330 |
|
402 |
277 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
973 |
971 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,048 |
1,031 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,800 |
1,779 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
613 |
611 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
170 |
153 |
$11K |
| D2331 |
|
191 |
135 |
$11K |
| D1120 |
Prophylaxis - child |
226 |
226 |
$7K |
| D9110 |
|
218 |
210 |
$7K |
| D1330 |
|
782 |
781 |
$5K |
| D1310 |
|
331 |
330 |
$3K |
| D0601 |
|
240 |
240 |
$2K |
| D0602 |
|
89 |
89 |
$890.00 |
| D0274 |
Bitewings - four radiographic images |
17 |
17 |
$473.45 |
| D0603 |
|
12 |
12 |
$120.00 |