| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,147 |
1,147 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
1,109 |
1,108 |
$24K |
| D0210 |
Intraoral - complete series of radiographic images |
531 |
531 |
$18K |
| D2335 |
|
248 |
74 |
$17K |
| D1120 |
Prophylaxis - child |
498 |
498 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
317 |
117 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
594 |
594 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
283 |
136 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
277 |
274 |
$8K |
| D0274 |
Bitewings - four radiographic images |
785 |
784 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
509 |
509 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
1,187 |
1,180 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
928 |
927 |
$3K |
| D1351 |
Sealant - per tooth |
136 |
18 |
$2K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$240.00 |