| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
875 |
752 |
$44K |
| D0274 |
Bitewings - four radiographic images |
636 |
590 |
$23K |
| D1120 |
Prophylaxis - child |
468 |
433 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
544 |
435 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
760 |
712 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
675 |
630 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,241 |
1,076 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,115 |
980 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
287 |
256 |
$11K |
| D1351 |
Sealant - per tooth |
275 |
54 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
182 |
116 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
55 |
29 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
13 |
$1K |
| D0272 |
Bitewings - two radiographic images |
27 |
27 |
$864.00 |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$392.00 |