| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,645 |
1,640 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
2,021 |
2,015 |
$36K |
| D1206 |
Topical application of fluoride varnish |
1,314 |
1,311 |
$20K |
| D0274 |
Bitewings - four radiographic images |
730 |
721 |
$16K |
| D1120 |
Prophylaxis - child |
335 |
335 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
259 |
252 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
236 |
158 |
$5K |
| D1351 |
Sealant - per tooth |
223 |
31 |
$5K |
| D0330 |
Panoramic radiographic image |
71 |
71 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
133 |
98 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
119 |
114 |
$965.29 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$340.00 |
| D0272 |
Bitewings - two radiographic images |
29 |
29 |
$312.68 |