| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,925 |
1,925 |
$96K |
| D0120 |
Periodic oral evaluation - established patient |
3,648 |
3,648 |
$82K |
| D1120 |
Prophylaxis - child |
1,796 |
1,796 |
$62K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
455 |
312 |
$46K |
| D0272 |
Bitewings - two radiographic images |
2,132 |
2,132 |
$40K |
| D1206 |
Topical application of fluoride varnish |
1,853 |
1,853 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
217 |
139 |
$17K |
| D0274 |
Bitewings - four radiographic images |
422 |
422 |
$12K |
| D0330 |
Panoramic radiographic image |
128 |
128 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
100 |
100 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
73 |
73 |
$1K |
| D1351 |
Sealant - per tooth |
32 |
12 |
$960.00 |
| D0140 |
Limited oral evaluation - problem focused |
18 |
18 |
$693.00 |
| D0220 |
Intraoral - periapical first radiographic image |
16 |
16 |
$205.28 |