| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,117 |
2,116 |
$115K |
| D0120 |
Periodic oral evaluation - established patient |
2,584 |
2,582 |
$71K |
| D1120 |
Prophylaxis - child |
1,295 |
1,295 |
$52K |
| D0274 |
Bitewings - four radiographic images |
1,368 |
1,367 |
$35K |
| D0330 |
Panoramic radiographic image |
949 |
949 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
767 |
767 |
$21K |
| D1206 |
Topical application of fluoride varnish |
623 |
623 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
877 |
877 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
128 |
109 |
$10K |
| D9110 |
|
112 |
112 |
$3K |
| D0272 |
Bitewings - two radiographic images |
126 |
126 |
$2K |
| D1351 |
Sealant - per tooth |
36 |
12 |
$1K |
| D4341 |
|
27 |
14 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
120 |
120 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
12 |
$766.55 |
| D1330 |
|
1,852 |
1,850 |
$0.00 |
| D0601 |
|
473 |
473 |
$0.00 |
| D0603 |
|
1,102 |
1,099 |
$0.00 |
| D1310 |
|
540 |
539 |
$0.00 |