| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
659 |
650 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
1,111 |
1,106 |
$12K |
| D1120 |
Prophylaxis - child |
647 |
642 |
$12K |
| D1206 |
Topical application of fluoride varnish |
922 |
917 |
$11K |
| D0274 |
Bitewings - four radiographic images |
276 |
273 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
125 |
54 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
180 |
172 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
89 |
84 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
37 |
24 |
$2K |
| D0272 |
Bitewings - two radiographic images |
125 |
125 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
42 |
41 |
$903.84 |
| D0220 |
Intraoral - periapical first radiographic image |
274 |
262 |
$857.27 |
| D0230 |
Intraoral - periapical each additional radiographic image |
34 |
29 |
$0.00 |
| D1351 |
Sealant - per tooth |
38 |
12 |
$0.00 |