| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,137 |
1,117 |
$38K |
| D0274 |
Bitewings - four radiographic images |
981 |
968 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
411 |
250 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
307 |
201 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
821 |
802 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
480 |
476 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,079 |
1,053 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,035 |
1,011 |
$8K |
| D1351 |
Sealant - per tooth |
207 |
28 |
$5K |
| D1330 |
|
439 |
421 |
$4K |
| D1310 |
|
311 |
293 |
$3K |
| D1120 |
Prophylaxis - child |
93 |
93 |
$2K |
| D1206 |
Topical application of fluoride varnish |
112 |
112 |
$2K |
| D9110 |
|
61 |
61 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
104 |
103 |
$2K |
| D2330 |
|
21 |
13 |
$915.54 |
| D0210 |
Intraoral - complete series of radiographic images |
17 |
17 |
$735.36 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$182.32 |