| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,518 |
2,518 |
$166K |
| D0120 |
Periodic oral evaluation - established patient |
3,988 |
3,988 |
$131K |
| D1120 |
Prophylaxis - child |
1,968 |
1,968 |
$96K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,089 |
2,089 |
$71K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
518 |
461 |
$64K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
530 |
473 |
$54K |
| D0274 |
Bitewings - four radiographic images |
1,532 |
1,532 |
$50K |
| D0210 |
Intraoral - complete series of radiographic images |
526 |
524 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
505 |
505 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
612 |
603 |
$9K |
| D1206 |
Topical application of fluoride varnish |
251 |
251 |
$9K |
| D1351 |
Sealant - per tooth |
51 |
27 |
$4K |
| D0330 |
Panoramic radiographic image |
65 |
65 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
39 |
39 |
$595.70 |