| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
5,690 |
5,690 |
$280K |
| D0274 |
Bitewings - four radiographic images |
4,936 |
4,936 |
$133K |
| D0120 |
Periodic oral evaluation - established patient |
5,007 |
5,007 |
$114K |
| D1206 |
Topical application of fluoride varnish |
5,680 |
5,680 |
$92K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
736 |
453 |
$74K |
| D0220 |
Intraoral - periapical first radiographic image |
4,667 |
4,653 |
$59K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,043 |
3,253 |
$32K |
| D0330 |
Panoramic radiographic image |
548 |
547 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
138 |
106 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
64 |
47 |
$7K |
| D1351 |
Sealant - per tooth |
229 |
60 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
159 |
159 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
79 |
79 |
$3K |