| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
955 |
943 |
$53K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
209 |
127 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
489 |
232 |
$19K |
| D0210 |
Intraoral - complete series of radiographic images |
109 |
108 |
$13K |
| D1120 |
Prophylaxis - child |
62 |
62 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
38 |
38 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
989 |
978 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
922 |
909 |
$1K |
| D1351 |
Sealant - per tooth |
304 |
86 |
$929.21 |
| D0274 |
Bitewings - four radiographic images |
721 |
713 |
$84.41 |
| D0220 |
Intraoral - periapical first radiographic image |
981 |
959 |
$30.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
1,185 |
1,169 |
$0.00 |
| D1330 |
|
1,212 |
1,196 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
38 |
38 |
$0.00 |
| D3120 |
|
17 |
15 |
$0.00 |