| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
773 |
760 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
1,437 |
1,408 |
$40K |
| D0274 |
Bitewings - four radiographic images |
802 |
788 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
235 |
122 |
$24K |
| D1120 |
Prophylaxis - child |
630 |
616 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,465 |
1,440 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,791 |
1,472 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,577 |
1,538 |
$19K |
| D0145 |
Oral evaluation for a patient under three years of age |
107 |
107 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
133 |
69 |
$11K |
| D0272 |
Bitewings - two radiographic images |
436 |
423 |
$10K |
| D1351 |
Sealant - per tooth |
192 |
36 |
$5K |
| D0330 |
Panoramic radiographic image |
130 |
125 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
23 |
12 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
16 |
$565.12 |
| D0350 |
|
28 |
28 |
$557.88 |
| D0603 |
|
928 |
912 |
$0.00 |
| D0602 |
|
468 |
455 |
$0.00 |
| D0601 |
|
213 |
211 |
$0.00 |