| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,153 |
1,152 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
1,412 |
1,411 |
$28K |
| D1120 |
Prophylaxis - child |
510 |
510 |
$15K |
| D1351 |
Sealant - per tooth |
586 |
120 |
$15K |
| D1206 |
Topical application of fluoride varnish |
800 |
800 |
$14K |
| D0274 |
Bitewings - four radiographic images |
498 |
497 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
214 |
156 |
$11K |
| D0330 |
Panoramic radiographic image |
280 |
280 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
425 |
425 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
140 |
120 |
$8K |
| D0272 |
Bitewings - two radiographic images |
276 |
276 |
$4K |
| D2330 |
|
67 |
46 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
371 |
370 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
36 |
28 |
$2K |
| D2331 |
|
29 |
24 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
155 |
114 |
$1K |