| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,494 |
1,488 |
$54K |
| D0274 |
Bitewings - four radiographic images |
1,254 |
1,248 |
$35K |
| D1351 |
Sealant - per tooth |
1,385 |
197 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,282 |
1,276 |
$26K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
319 |
174 |
$19K |
| D9110 |
|
626 |
620 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
788 |
786 |
$16K |
| D0330 |
Panoramic radiographic image |
382 |
380 |
$14K |
| D1120 |
Prophylaxis - child |
465 |
464 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
235 |
124 |
$11K |
| D1206 |
Topical application of fluoride varnish |
577 |
574 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
1,290 |
1,230 |
$10K |
| D1330 |
|
913 |
911 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
160 |
157 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
620 |
611 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
119 |
119 |
$2K |
| D0601 |
|
166 |
166 |
$2K |
| D9920 |
|
12 |
12 |
$2K |
| D0602 |
|
81 |
81 |
$810.00 |
| D1310 |
|
65 |
65 |
$455.01 |
| D0272 |
Bitewings - two radiographic images |
28 |
28 |
$448.00 |