| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
576 |
574 |
$21K |
| D0274 |
Bitewings - four radiographic images |
720 |
716 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
426 |
424 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
163 |
112 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
392 |
389 |
$10K |
| D0330 |
Panoramic radiographic image |
148 |
145 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
662 |
641 |
$5K |
| D1206 |
Topical application of fluoride varnish |
243 |
243 |
$4K |
| D1120 |
Prophylaxis - child |
127 |
126 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
449 |
443 |
$4K |
| D9110 |
|
107 |
106 |
$3K |
| D1351 |
Sealant - per tooth |
84 |
12 |
$2K |
| D1330 |
|
65 |
65 |
$451.40 |