| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,264 |
1,258 |
$67K |
| D0120 |
Periodic oral evaluation - established patient |
1,514 |
1,510 |
$37K |
| D0330 |
Panoramic radiographic image |
629 |
626 |
$31K |
| D1120 |
Prophylaxis - child |
342 |
342 |
$19K |
| D0274 |
Bitewings - four radiographic images |
473 |
473 |
$16K |
| D1206 |
Topical application of fluoride varnish |
424 |
423 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
729 |
704 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
111 |
109 |
$5K |
| D1351 |
Sealant - per tooth |
205 |
36 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
15 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
13 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
191 |
187 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
28 |
26 |
$1K |
| D0272 |
Bitewings - two radiographic images |
25 |
25 |
$500.00 |