| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
507 |
482 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
659 |
622 |
$16K |
| D0274 |
Bitewings - four radiographic images |
546 |
515 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
146 |
80 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
879 |
809 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
815 |
736 |
$7K |
| D1206 |
Topical application of fluoride varnish |
468 |
447 |
$6K |
| D1120 |
Prophylaxis - child |
175 |
167 |
$5K |
| D1351 |
Sealant - per tooth |
157 |
34 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
195 |
190 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
45 |
43 |
$1K |
| D0330 |
Panoramic radiographic image |
40 |
38 |
$1K |
| D0272 |
Bitewings - two radiographic images |
28 |
27 |
$603.20 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$282.56 |
| D9910 |
|
110 |
42 |
$23.88 |
| D1999 |
|
27 |
24 |
$0.00 |
| D0603 |
|
973 |
921 |
$0.00 |
| D1330 |
|
20 |
20 |
$0.00 |