| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
5,848 |
5,840 |
$194K |
| D0120 |
Periodic oral evaluation - established patient |
8,711 |
8,701 |
$151K |
| D1351 |
Sealant - per tooth |
3,076 |
931 |
$88K |
| D1120 |
Prophylaxis - child |
2,760 |
2,758 |
$72K |
| D0330 |
Panoramic radiographic image |
2,948 |
2,945 |
$72K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,117 |
819 |
$58K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,210 |
751 |
$43K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,528 |
4,526 |
$43K |
| D0140 |
Limited oral evaluation - problem focused |
1,430 |
1,423 |
$17K |
| D0274 |
Bitewings - four radiographic images |
1,034 |
1,030 |
$15K |
| D9997 |
|
513 |
511 |
$15K |
| D9920 |
|
702 |
691 |
$15K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
219 |
190 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
1,219 |
1,216 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
881 |
873 |
$5K |
| D9110 |
|
28 |
28 |
$338.99 |