| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,242 |
1,233 |
$44K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
532 |
339 |
$31K |
| D1351 |
Sealant - per tooth |
1,072 |
155 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
509 |
318 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
1,071 |
1,065 |
$22K |
| D0274 |
Bitewings - four radiographic images |
464 |
461 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
285 |
279 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
425 |
420 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
133 |
104 |
$8K |
| D9110 |
|
231 |
227 |
$7K |
| D1206 |
Topical application of fluoride varnish |
377 |
376 |
$7K |
| D1120 |
Prophylaxis - child |
201 |
201 |
$6K |
| D0330 |
Panoramic radiographic image |
143 |
143 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
329 |
325 |
$3K |
| D2335 |
|
35 |
26 |
$2K |
| D2332 |
|
39 |
25 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
178 |
122 |
$2K |
| D2331 |
|
20 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
26 |
26 |
$416.00 |