| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
707 |
702 |
$46K |
| D0120 |
Periodic oral evaluation - established patient |
1,200 |
1,186 |
$36K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,250 |
1,235 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
216 |
116 |
$29K |
| D1120 |
Prophylaxis - child |
508 |
504 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
238 |
236 |
$13K |
| D0330 |
Panoramic radiographic image |
216 |
216 |
$10K |
| D0274 |
Bitewings - four radiographic images |
401 |
398 |
$10K |
| D1351 |
Sealant - per tooth |
239 |
52 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
426 |
412 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
40 |
18 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
14 |
$3K |
| D1330 |
|
471 |
469 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
197 |
194 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
15 |
15 |
$708.90 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$195.00 |