| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
907 |
907 |
$46K |
| D0120 |
Periodic oral evaluation - established patient |
1,575 |
1,575 |
$41K |
| D1120 |
Prophylaxis - child |
996 |
996 |
$37K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,163 |
1,163 |
$25K |
| D0210 |
Intraoral - complete series of radiographic images |
196 |
196 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
188 |
188 |
$8K |
| D0274 |
Bitewings - four radiographic images |
132 |
132 |
$4K |
| D1351 |
Sealant - per tooth |
146 |
33 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
25 |
17 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
39 |
37 |
$608.49 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$561.40 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$275.00 |