| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
217 |
205 |
$9K |
| D0330 |
Panoramic radiographic image |
156 |
150 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
314 |
291 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
127 |
123 |
$5K |
| D1206 |
Topical application of fluoride varnish |
252 |
235 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
114 |
109 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
169 |
81 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
221 |
179 |
$2K |
| D0274 |
Bitewings - four radiographic images |
98 |
89 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
46 |
27 |
$2K |
| D1120 |
Prophylaxis - child |
68 |
61 |
$1K |
| D1351 |
Sealant - per tooth |
96 |
12 |
$0.00 |