| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,714 |
1,714 |
$86K |
| D0120 |
Periodic oral evaluation - established patient |
2,208 |
2,208 |
$51K |
| D0274 |
Bitewings - four radiographic images |
1,442 |
1,442 |
$39K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
376 |
219 |
$38K |
| D1206 |
Topical application of fluoride varnish |
2,108 |
2,108 |
$35K |
| D1120 |
Prophylaxis - child |
603 |
603 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,558 |
1,547 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,816 |
1,331 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
183 |
99 |
$14K |
| D0330 |
Panoramic radiographic image |
158 |
158 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
77 |
77 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
129 |
129 |
$2K |
| D1351 |
Sealant - per tooth |
39 |
13 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$462.00 |