| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,475 |
3,475 |
$146K |
| D0120 |
Periodic oral evaluation - established patient |
3,866 |
3,865 |
$82K |
| D0274 |
Bitewings - four radiographic images |
3,520 |
3,518 |
$74K |
| D1120 |
Prophylaxis - child |
1,547 |
1,546 |
$48K |
| D0220 |
Intraoral - periapical first radiographic image |
4,278 |
4,278 |
$41K |
| D0350 |
|
3,784 |
3,784 |
$36K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,307 |
4,293 |
$29K |
| D0210 |
Intraoral - complete series of radiographic images |
1,331 |
1,329 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,242 |
2,241 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,110 |
1,110 |
$24K |
| D1351 |
Sealant - per tooth |
210 |
123 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
47 |
38 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
65 |
61 |
$3K |
| D0272 |
Bitewings - two radiographic images |
234 |
234 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$162.82 |
| D1330 |
|
12 |
12 |
$0.00 |
| D1999 |
|
51 |
51 |
$0.00 |