| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
812 |
799 |
$88K |
| D1120 |
Prophylaxis - child |
616 |
602 |
$39K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
278 |
198 |
$33K |
| D0330 |
Panoramic radiographic image |
146 |
146 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
948 |
933 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
219 |
153 |
$17K |
| D0274 |
Bitewings - four radiographic images |
376 |
367 |
$11K |
| D1351 |
Sealant - per tooth |
622 |
165 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
90 |
87 |
$8K |
| D1330 |
|
1,502 |
1,478 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,601 |
1,573 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
105 |
103 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
15 |
15 |
$601.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
12 |
12 |
$375.00 |