| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,989 |
1,923 |
$98K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
870 |
574 |
$76K |
| D0120 |
Periodic oral evaluation - established patient |
2,927 |
2,827 |
$74K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
340 |
255 |
$44K |
| D0274 |
Bitewings - four radiographic images |
1,249 |
1,214 |
$39K |
| D1351 |
Sealant - per tooth |
1,461 |
312 |
$34K |
| D1206 |
Topical application of fluoride varnish |
1,628 |
1,544 |
$33K |
| D1120 |
Prophylaxis - child |
954 |
941 |
$32K |
| D0330 |
Panoramic radiographic image |
262 |
257 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
780 |
775 |
$14K |
| D4346 |
|
65 |
62 |
$5K |
| D0272 |
Bitewings - two radiographic images |
175 |
174 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
24 |
24 |
$957.00 |
| D0220 |
Intraoral - periapical first radiographic image |
15 |
14 |
$264.00 |
| D9986 |
|
12 |
12 |
$0.00 |