| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,554 |
1,534 |
$96K |
| D1206 |
Topical application of fluoride varnish |
3,434 |
3,388 |
$86K |
| D0120 |
Periodic oral evaluation - established patient |
2,747 |
2,707 |
$82K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
625 |
331 |
$80K |
| D1120 |
Prophylaxis - child |
1,381 |
1,358 |
$59K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
252 |
103 |
$26K |
| D0274 |
Bitewings - four radiographic images |
744 |
738 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,413 |
1,386 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
189 |
184 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,157 |
1,142 |
$7K |
| D1330 |
|
1,141 |
1,123 |
$7K |
| D1351 |
Sealant - per tooth |
113 |
27 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
23 |
13 |
$3K |
| D0272 |
Bitewings - two radiographic images |
93 |
92 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$855.00 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$597.35 |