| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
920 |
916 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,110 |
1,105 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,296 |
1,247 |
$20K |
| D0330 |
Panoramic radiographic image |
377 |
376 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
221 |
169 |
$12K |
| D0272 |
Bitewings - two radiographic images |
628 |
624 |
$10K |
| D0274 |
Bitewings - four radiographic images |
373 |
372 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
1,258 |
1,252 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
118 |
89 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
345 |
344 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
316 |
314 |
$6K |
| D1330 |
|
616 |
612 |
$5K |
| D1120 |
Prophylaxis - child |
136 |
136 |
$4K |
| D1351 |
Sealant - per tooth |
146 |
25 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$630.00 |