| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
974 |
967 |
$36K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
448 |
291 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
1,298 |
1,290 |
$26K |
| D1120 |
Prophylaxis - child |
606 |
602 |
$19K |
| D1351 |
Sealant - per tooth |
616 |
142 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
262 |
180 |
$13K |
| D0274 |
Bitewings - four radiographic images |
439 |
436 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
171 |
136 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
442 |
439 |
$8K |
| D1206 |
Topical application of fluoride varnish |
382 |
380 |
$7K |
| D0272 |
Bitewings - two radiographic images |
415 |
414 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
176 |
175 |
$4K |
| D0330 |
Panoramic radiographic image |
85 |
85 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
238 |
237 |
$2K |
| D2331 |
|
26 |
14 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$104.24 |