| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,210 |
1,210 |
$53K |
| D0120 |
Periodic oral evaluation - established patient |
1,536 |
1,536 |
$37K |
| D0274 |
Bitewings - four radiographic images |
1,397 |
1,397 |
$35K |
| D1120 |
Prophylaxis - child |
567 |
567 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,509 |
1,501 |
$19K |
| D1351 |
Sealant - per tooth |
512 |
129 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
278 |
175 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
930 |
930 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
362 |
362 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
123 |
54 |
$5K |
| D0330 |
Panoramic radiographic image |
206 |
206 |
$5K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
28 |
12 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
75 |
75 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
68 |
68 |
$600.90 |