| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
502 |
477 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
855 |
825 |
$21K |
| D1120 |
Prophylaxis - child |
404 |
388 |
$19K |
| D0274 |
Bitewings - four radiographic images |
442 |
422 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
566 |
529 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
703 |
678 |
$11K |
| D0330 |
Panoramic radiographic image |
138 |
129 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
611 |
520 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
154 |
139 |
$6K |
| D1351 |
Sealant - per tooth |
113 |
29 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
39 |
27 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
44 |
26 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
65 |
64 |
$2K |
| D1206 |
Topical application of fluoride varnish |
15 |
15 |
$364.00 |