| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
985 |
985 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
1,930 |
1,928 |
$49K |
| D1120 |
Prophylaxis - child |
1,167 |
1,165 |
$43K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
311 |
229 |
$36K |
| D1206 |
Topical application of fluoride varnish |
1,471 |
1,469 |
$34K |
| D0274 |
Bitewings - four radiographic images |
674 |
674 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
182 |
138 |
$16K |
| D0330 |
Panoramic radiographic image |
113 |
113 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
133 |
133 |
$5K |
| D0272 |
Bitewings - two radiographic images |
250 |
250 |
$5K |
| D1351 |
Sealant - per tooth |
108 |
24 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
38 |
38 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
27 |
27 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$194.42 |