| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,621 |
1,614 |
$64K |
| D0120 |
Periodic oral evaluation - established patient |
1,774 |
1,762 |
$52K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
492 |
324 |
$42K |
| D0330 |
Panoramic radiographic image |
837 |
830 |
$38K |
| D0274 |
Bitewings - four radiographic images |
1,012 |
1,009 |
$34K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
246 |
170 |
$28K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
332 |
226 |
$25K |
| D1120 |
Prophylaxis - child |
524 |
518 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
561 |
557 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,024 |
1,008 |
$14K |
| D1206 |
Topical application of fluoride varnish |
682 |
674 |
$12K |
| D1310 |
|
447 |
445 |
$9K |
| D9110 |
|
248 |
245 |
$9K |
| D1351 |
Sealant - per tooth |
257 |
58 |
$7K |
| D0272 |
Bitewings - two radiographic images |
313 |
308 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
334 |
330 |
$4K |
| D1330 |
|
482 |
480 |
$4K |
| D2330 |
|
41 |
28 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
151 |
151 |
$3K |
| D2332 |
|
19 |
12 |
$2K |
| D0602 |
|
16 |
16 |
$160.00 |