| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,227 |
1,214 |
$41K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
506 |
307 |
$29K |
| D0274 |
Bitewings - four radiographic images |
884 |
875 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
392 |
241 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
918 |
900 |
$17K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
248 |
141 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
464 |
463 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
742 |
723 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
529 |
476 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
245 |
242 |
$4K |
| D1351 |
Sealant - per tooth |
125 |
16 |
$3K |
| D1120 |
Prophylaxis - child |
55 |
55 |
$1K |
| D2332 |
|
20 |
12 |
$1K |
| D2330 |
|
20 |
15 |
$880.48 |
| D0210 |
Intraoral - complete series of radiographic images |
17 |
17 |
$727.77 |
| D0272 |
Bitewings - two radiographic images |
39 |
39 |
$561.04 |
| D9110 |
|
13 |
12 |
$351.15 |