| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,256 |
1,253 |
$45K |
| D1351 |
Sealant - per tooth |
1,187 |
196 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
464 |
333 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
997 |
994 |
$21K |
| D0330 |
Panoramic radiographic image |
571 |
571 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
322 |
261 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
522 |
521 |
$11K |
| D0272 |
Bitewings - two radiographic images |
532 |
529 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
366 |
366 |
$7K |
| D1120 |
Prophylaxis - child |
188 |
188 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
704 |
701 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
621 |
328 |
$5K |
| D2330 |
|
70 |
49 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
14 |
$913.29 |
| D2331 |
|
15 |
12 |
$900.00 |
| D9110 |
|
14 |
14 |
$420.00 |
| D1310 |
|
42 |
42 |
$210.00 |
| D1330 |
|
42 |
42 |
$210.00 |