| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,312 |
1,138 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
1,509 |
1,294 |
$15K |
| D0330 |
Panoramic radiographic image |
619 |
536 |
$15K |
| D1120 |
Prophylaxis - child |
401 |
351 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
100 |
100 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
880 |
789 |
$4K |
| D0274 |
Bitewings - four radiographic images |
1,828 |
1,585 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,608 |
1,392 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
37 |
15 |
$883.44 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
109 |
53 |
$870.00 |
| D1330 |
|
1,740 |
1,509 |
$178.00 |
| D0272 |
Bitewings - two radiographic images |
79 |
71 |
$143.00 |
| D1999 |
|
12 |
12 |
$25.00 |
| D0220 |
Intraoral - periapical first radiographic image |
130 |
106 |
$4.00 |
| D1351 |
Sealant - per tooth |
487 |
68 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
67 |
52 |
$0.00 |