| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
931 |
931 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
1,156 |
1,155 |
$33K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
216 |
142 |
$27K |
| D0274 |
Bitewings - four radiographic images |
901 |
901 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
943 |
942 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
161 |
161 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
430 |
430 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
45 |
35 |
$4K |
| D1120 |
Prophylaxis - child |
111 |
111 |
$4K |
| D1351 |
Sealant - per tooth |
64 |
18 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
75 |
75 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
159 |
159 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
26 |
26 |
$864.50 |
| D0272 |
Bitewings - two radiographic images |
21 |
21 |
$399.00 |