| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,132 |
1,130 |
$68K |
| D0120 |
Periodic oral evaluation - established patient |
1,412 |
1,412 |
$43K |
| D0274 |
Bitewings - four radiographic images |
506 |
505 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
130 |
95 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
430 |
430 |
$7K |
| D1120 |
Prophylaxis - child |
143 |
143 |
$6K |
| D0330 |
Panoramic radiographic image |
145 |
145 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
213 |
210 |
$3K |
| D1351 |
Sealant - per tooth |
18 |
13 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
28 |
28 |
$745.00 |
| D1206 |
Topical application of fluoride varnish |
16 |
16 |
$600.00 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$220.50 |