| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,797 |
1,797 |
$65K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,496 |
593 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
2,348 |
2,346 |
$45K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
405 |
225 |
$21K |
| D0330 |
Panoramic radiographic image |
772 |
772 |
$20K |
| D0274 |
Bitewings - four radiographic images |
929 |
929 |
$17K |
| D2750 |
|
49 |
28 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,217 |
1,212 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,224 |
1,214 |
$8K |
| D1120 |
Prophylaxis - child |
256 |
256 |
$7K |
| D1351 |
Sealant - per tooth |
158 |
40 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
140 |
140 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
269 |
269 |
$3K |
| D1206 |
Topical application of fluoride varnish |
98 |
98 |
$2K |
| D2330 |
|
41 |
13 |
$1K |
| D0272 |
Bitewings - two radiographic images |
42 |
42 |
$328.00 |