| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
460 |
425 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
612 |
583 |
$18K |
| D1206 |
Topical application of fluoride varnish |
689 |
642 |
$17K |
| D0274 |
Bitewings - four radiographic images |
312 |
279 |
$11K |
| D1120 |
Prophylaxis - child |
295 |
270 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
178 |
151 |
$7K |
| D0330 |
Panoramic radiographic image |
114 |
94 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
13 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
137 |
119 |
$2K |
| D1351 |
Sealant - per tooth |
76 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
126 |
41 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
40 |
32 |
$2K |
| D0272 |
Bitewings - two radiographic images |
26 |
25 |
$746.40 |