| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,419 |
1,419 |
$71K |
| D0120 |
Periodic oral evaluation - established patient |
2,015 |
2,015 |
$46K |
| D1120 |
Prophylaxis - child |
1,062 |
1,062 |
$37K |
| D0274 |
Bitewings - four radiographic images |
1,288 |
1,288 |
$35K |
| D1206 |
Topical application of fluoride varnish |
1,687 |
1,687 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
1,562 |
1,550 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,124 |
1,099 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
116 |
73 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
237 |
237 |
$9K |
| D0330 |
Panoramic radiographic image |
134 |
134 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
279 |
279 |
$4K |
| D1351 |
Sealant - per tooth |
146 |
39 |
$4K |
| D0272 |
Bitewings - two radiographic images |
199 |
199 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
28 |
28 |
$1K |