| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,403 |
1,403 |
$70K |
| D0274 |
Bitewings - four radiographic images |
2,017 |
2,017 |
$54K |
| D0120 |
Periodic oral evaluation - established patient |
1,360 |
1,360 |
$31K |
| D1206 |
Topical application of fluoride varnish |
1,732 |
1,732 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
1,638 |
1,614 |
$21K |
| D0330 |
Panoramic radiographic image |
294 |
293 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,298 |
1,288 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
74 |
40 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
170 |
170 |
$7K |
| D1120 |
Prophylaxis - child |
135 |
135 |
$5K |
| D1351 |
Sealant - per tooth |
131 |
41 |
$4K |