| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,509 |
1,509 |
$69K |
| D0120 |
Periodic oral evaluation - established patient |
1,458 |
1,458 |
$38K |
| D0274 |
Bitewings - four radiographic images |
1,059 |
1,059 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,424 |
1,413 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
63 |
38 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,256 |
1,253 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
142 |
142 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
75 |
75 |
$4K |
| D1120 |
Prophylaxis - child |
59 |
59 |
$3K |
| D0330 |
Panoramic radiographic image |
50 |
50 |
$2K |
| D1351 |
Sealant - per tooth |
69 |
12 |
$2K |
| D1206 |
Topical application of fluoride varnish |
55 |
55 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
46 |
46 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
25 |
25 |
$1K |