| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
757 |
753 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
1,305 |
1,300 |
$26K |
| D1120 |
Prophylaxis - child |
472 |
472 |
$16K |
| D0274 |
Bitewings - four radiographic images |
531 |
530 |
$15K |
| D1206 |
Topical application of fluoride varnish |
685 |
685 |
$12K |
| D1351 |
Sealant - per tooth |
287 |
61 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
254 |
254 |
$5K |
| D0330 |
Panoramic radiographic image |
136 |
136 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
78 |
53 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
39 |
29 |
$3K |
| D9110 |
|
71 |
71 |
$2K |
| D0272 |
Bitewings - two radiographic images |
114 |
114 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
90 |
89 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
150 |
149 |
$1K |