| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,425 |
1,388 |
$92K |
| D0120 |
Periodic oral evaluation - established patient |
2,271 |
2,209 |
$83K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
389 |
185 |
$15K |
| D0330 |
Panoramic radiographic image |
194 |
191 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
13 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
28 |
28 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,451 |
2,388 |
$2K |
| D1351 |
Sealant - per tooth |
662 |
168 |
$1K |
| D0274 |
Bitewings - four radiographic images |
1,425 |
1,388 |
$968.73 |
| D1120 |
Prophylaxis - child |
972 |
948 |
$960.07 |
| D0220 |
Intraoral - periapical first radiographic image |
2,551 |
2,491 |
$644.33 |
| D0340 |
|
61 |
59 |
$578.72 |
| D0272 |
Bitewings - two radiographic images |
906 |
886 |
$542.22 |
| D1330 |
|
2,455 |
2,391 |
$428.56 |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,458 |
2,394 |
$392.00 |
| D0240 |
|
389 |
380 |
$236.62 |
| D3120 |
|
280 |
155 |
$49.04 |
| D0350 |
|
1,017 |
981 |
$39.62 |