| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,858 |
1,835 |
$114K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
689 |
352 |
$94K |
| D0120 |
Periodic oral evaluation - established patient |
2,693 |
2,666 |
$80K |
| D1120 |
Prophylaxis - child |
1,261 |
1,251 |
$55K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,318 |
2,297 |
$53K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
219 |
144 |
$38K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
509 |
507 |
$28K |
| D1206 |
Topical application of fluoride varnish |
734 |
728 |
$19K |
| D0210 |
Intraoral - complete series of radiographic images |
263 |
261 |
$15K |
| D1351 |
Sealant - per tooth |
414 |
70 |
$14K |
| D0274 |
Bitewings - four radiographic images |
540 |
537 |
$12K |
| D1330 |
|
1,598 |
1,582 |
$9K |
| D0330 |
Panoramic radiographic image |
156 |
156 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
48 |
28 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
92 |
84 |
$1K |
| D0272 |
Bitewings - two radiographic images |
59 |
59 |
$904.74 |