| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,684 |
1,684 |
$92K |
| D7241 |
|
304 |
170 |
$90K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
792 |
462 |
$68K |
| D0120 |
Periodic oral evaluation - established patient |
2,219 |
2,219 |
$61K |
| D1120 |
Prophylaxis - child |
972 |
972 |
$42K |
| D0274 |
Bitewings - four radiographic images |
929 |
929 |
$25K |
| D0210 |
Intraoral - complete series of radiographic images |
705 |
701 |
$25K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
157 |
121 |
$16K |
| D1351 |
Sealant - per tooth |
266 |
115 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,031 |
1,031 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,086 |
1,061 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
243 |
169 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
371 |
371 |
$11K |
| D2750 |
|
14 |
12 |
$8K |
| D1206 |
Topical application of fluoride varnish |
230 |
230 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
388 |
388 |
$5K |
| D9310 |
|
51 |
51 |
$4K |
| D0272 |
Bitewings - two radiographic images |
149 |
149 |
$2K |
| D9110 |
|
13 |
13 |
$356.12 |