| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
274 |
268 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
385 |
379 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
113 |
68 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
92 |
91 |
$4K |
| D0274 |
Bitewings - four radiographic images |
132 |
132 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
152 |
152 |
$3K |
| D1351 |
Sealant - per tooth |
79 |
14 |
$2K |
| D1120 |
Prophylaxis - child |
66 |
66 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
214 |
210 |
$2K |
| D0330 |
Panoramic radiographic image |
31 |
31 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
127 |
122 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
25 |
25 |
$547.25 |