| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
5,097 |
5,094 |
$260K |
| D0120 |
Periodic oral evaluation - established patient |
4,998 |
4,997 |
$130K |
| D0274 |
Bitewings - four radiographic images |
3,589 |
3,588 |
$120K |
| D0330 |
Panoramic radiographic image |
2,174 |
2,174 |
$90K |
| D1120 |
Prophylaxis - child |
1,790 |
1,790 |
$70K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
763 |
592 |
$59K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,113 |
2,113 |
$59K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,857 |
1,857 |
$26K |
| D0272 |
Bitewings - two radiographic images |
661 |
661 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
205 |
152 |
$10K |
| D1206 |
Topical application of fluoride varnish |
317 |
317 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
280 |
273 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
13 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
90 |
90 |
$1K |
| D1351 |
Sealant - per tooth |
36 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
86 |
67 |
$692.10 |