| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
642 |
391 |
$8K |
| D0274 |
Bitewings - four radiographic images |
776 |
499 |
$6K |
| D1351 |
Sealant - per tooth |
712 |
68 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
624 |
391 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
473 |
310 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
1,335 |
818 |
$4K |
| D1206 |
Topical application of fluoride varnish |
579 |
361 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,424 |
726 |
$3K |
| D1120 |
Prophylaxis - child |
283 |
180 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
63 |
38 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
54 |
39 |
$508.25 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
131 |
38 |
$498.28 |
| D0272 |
Bitewings - two radiographic images |
106 |
46 |
$361.53 |
| D1999 |
|
1,108 |
504 |
$0.00 |