| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,769 |
1,767 |
$124K |
| D1120 |
Prophylaxis - child |
861 |
861 |
$43K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
742 |
361 |
$43K |
| D0330 |
Panoramic radiographic image |
223 |
223 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$2K |
| D1351 |
Sealant - per tooth |
185 |
29 |
$2K |
| D0274 |
Bitewings - four radiographic images |
1,313 |
1,313 |
$591.32 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
12 |
$469.00 |
| D0120 |
Periodic oral evaluation - established patient |
2,339 |
2,338 |
$467.77 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
62 |
62 |
$443.80 |
| D0220 |
Intraoral - periapical first radiographic image |
150 |
145 |
$34.82 |
| D1206 |
Topical application of fluoride varnish |
284 |
284 |
$32.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
2,039 |
2,038 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
464 |
464 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
52 |
27 |
$0.00 |