| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,498 |
1,342 |
$56K |
| D2332 |
|
814 |
383 |
$50K |
| D1120 |
Prophylaxis - child |
850 |
793 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
1,947 |
1,774 |
$32K |
| D0330 |
Panoramic radiographic image |
933 |
871 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
441 |
175 |
$20K |
| D1206 |
Topical application of fluoride varnish |
1,158 |
1,093 |
$15K |
| D2335 |
|
161 |
96 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
177 |
123 |
$10K |
| D0272 |
Bitewings - two radiographic images |
593 |
564 |
$9K |
| D1351 |
Sealant - per tooth |
351 |
78 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
257 |
230 |
$6K |
| D2394 |
|
65 |
43 |
$4K |
| D2331 |
|
69 |
47 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
128 |
126 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
302 |
247 |
$3K |
| D0274 |
Bitewings - four radiographic images |
118 |
102 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
12 |
$990.00 |
| D9110 |
|
15 |
15 |
$359.10 |
| D0220 |
Intraoral - periapical first radiographic image |
31 |
28 |
$212.28 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
12 |
$61.83 |