| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
853 |
850 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
486 |
259 |
$29K |
| D0274 |
Bitewings - four radiographic images |
816 |
813 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
554 |
552 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
552 |
552 |
$14K |
| D0330 |
Panoramic radiographic image |
325 |
323 |
$12K |
| D1351 |
Sealant - per tooth |
429 |
58 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
117 |
73 |
$8K |
| D1206 |
Topical application of fluoride varnish |
382 |
382 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
719 |
703 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
113 |
69 |
$5K |
| D1120 |
Prophylaxis - child |
153 |
153 |
$5K |
| D9920 |
|
43 |
43 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
525 |
521 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
122 |
120 |
$4K |
| D1330 |
|
519 |
519 |
$3K |
| D1310 |
|
300 |
300 |
$2K |
| D2332 |
|
21 |
12 |
$1K |
| D0601 |
|
71 |
71 |
$610.00 |