| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
866 |
858 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
890 |
886 |
$30K |
| D0274 |
Bitewings - four radiographic images |
614 |
610 |
$18K |
| D1999 |
|
1,387 |
1,278 |
$14K |
| D1206 |
Topical application of fluoride varnish |
337 |
335 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
70 |
43 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
223 |
218 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
181 |
179 |
$8K |
| D1120 |
Prophylaxis - child |
111 |
111 |
$4K |
| D1351 |
Sealant - per tooth |
80 |
13 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
277 |
257 |
$3K |
| D0330 |
Panoramic radiographic image |
41 |
41 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
13 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
37 |
20 |
$381.94 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$369.53 |