| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
834 |
826 |
$30K |
| D0330 |
Panoramic radiographic image |
526 |
524 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
956 |
947 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
221 |
156 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
282 |
197 |
$15K |
| D0274 |
Bitewings - four radiographic images |
370 |
367 |
$10K |
| D1120 |
Prophylaxis - child |
298 |
296 |
$9K |
| D1351 |
Sealant - per tooth |
344 |
108 |
$9K |
| D9110 |
|
203 |
194 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
606 |
594 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
259 |
255 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
313 |
309 |
$6K |
| D0272 |
Bitewings - two radiographic images |
197 |
194 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
300 |
192 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
14 |
$2K |
| D1206 |
Topical application of fluoride varnish |
92 |
92 |
$2K |
| D1330 |
|
81 |
81 |
$405.00 |
| D0602 |
|
29 |
29 |
$290.00 |
| D0701 |
|
28 |
27 |
$0.00 |
| D0707 |
|
30 |
28 |
$0.00 |