| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,855 |
1,855 |
$83K |
| D0274 |
Bitewings - four radiographic images |
2,007 |
2,007 |
$48K |
| D0120 |
Periodic oral evaluation - established patient |
1,927 |
1,926 |
$46K |
| D0220 |
Intraoral - periapical first radiographic image |
2,183 |
2,172 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
238 |
136 |
$16K |
| D1120 |
Prophylaxis - child |
334 |
334 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
398 |
398 |
$9K |
| D2954 |
|
57 |
30 |
$8K |
| D0330 |
Panoramic radiographic image |
302 |
302 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
581 |
581 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
596 |
596 |
$6K |
| D1351 |
Sealant - per tooth |
158 |
37 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
127 |
72 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
154 |
154 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
53 |
53 |
$1K |
| D0272 |
Bitewings - two radiographic images |
35 |
35 |
$474.90 |