| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,647 |
4,647 |
$247K |
| D0120 |
Periodic oral evaluation - established patient |
5,202 |
5,201 |
$140K |
| D0274 |
Bitewings - four radiographic images |
2,681 |
2,681 |
$86K |
| D1120 |
Prophylaxis - child |
1,788 |
1,787 |
$72K |
| D0330 |
Panoramic radiographic image |
1,105 |
1,105 |
$44K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,242 |
1,242 |
$36K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,742 |
1,742 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
213 |
184 |
$17K |
| D0272 |
Bitewings - two radiographic images |
543 |
543 |
$10K |
| D1206 |
Topical application of fluoride varnish |
359 |
359 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
48 |
47 |
$4K |
| D1351 |
Sealant - per tooth |
30 |
12 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
67 |
67 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
14 |
$770.68 |