| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,382 |
1,382 |
$75K |
| D0120 |
Periodic oral evaluation - established patient |
1,909 |
1,909 |
$52K |
| D1120 |
Prophylaxis - child |
971 |
971 |
$38K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
260 |
240 |
$28K |
| D0274 |
Bitewings - four radiographic images |
871 |
871 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
273 |
263 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
349 |
349 |
$9K |
| D0330 |
Panoramic radiographic image |
226 |
226 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
363 |
353 |
$5K |
| D1206 |
Topical application of fluoride varnish |
108 |
108 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
161 |
156 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
84 |
83 |
$2K |
| D1351 |
Sealant - per tooth |
15 |
15 |
$2K |
| D0272 |
Bitewings - two radiographic images |
105 |
105 |
$2K |
| D0350 |
|
89 |
89 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
26 |
26 |
$364.00 |
| D1330 |
|
833 |
833 |
$0.00 |
| D1999 |
|
213 |
203 |
$0.00 |