| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
940 |
924 |
$29K |
| D0274 |
Bitewings - four radiographic images |
1,001 |
983 |
$25K |
| D1351 |
Sealant - per tooth |
472 |
123 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
304 |
202 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
812 |
790 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
215 |
154 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,079 |
1,055 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
1,088 |
1,065 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
394 |
390 |
$7K |
| D1310 |
|
1,135 |
1,110 |
$6K |
| D1330 |
|
1,136 |
1,110 |
$6K |
| D1206 |
Topical application of fluoride varnish |
297 |
283 |
$5K |
| D1120 |
Prophylaxis - child |
130 |
122 |
$3K |
| D9110 |
|
38 |
38 |
$1K |
| D2331 |
|
15 |
12 |
$743.76 |