| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,465 |
1,396 |
$65K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
561 |
296 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
1,825 |
1,717 |
$37K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
654 |
348 |
$27K |
| D1120 |
Prophylaxis - child |
632 |
617 |
$20K |
| D0330 |
Panoramic radiographic image |
286 |
283 |
$19K |
| D1351 |
Sealant - per tooth |
2,800 |
776 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
1,694 |
1,573 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
234 |
232 |
$757.39 |
| D1330 |
|
2,259 |
2,146 |
$538.80 |
| D0274 |
Bitewings - four radiographic images |
1,440 |
1,378 |
$278.60 |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,357 |
1,319 |
$250.11 |
| D1206 |
Topical application of fluoride varnish |
1,718 |
1,630 |
$200.04 |
| D1208 |
Topical application of fluoride, excluding varnish |
380 |
375 |
$196.20 |
| D0272 |
Bitewings - two radiographic images |
644 |
628 |
$40.32 |