| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
272 |
268 |
$10K |
| D0274 |
Bitewings - four radiographic images |
297 |
293 |
$8K |
| D0330 |
Panoramic radiographic image |
143 |
139 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
230 |
226 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
185 |
181 |
$3K |
| D1351 |
Sealant - per tooth |
104 |
12 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
95 |
95 |
$2K |
| D1120 |
Prophylaxis - child |
40 |
40 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$450.00 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$226.66 |