| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,871 |
1,865 |
$83K |
| D0120 |
Periodic oral evaluation - established patient |
2,437 |
2,434 |
$73K |
| D1206 |
Topical application of fluoride varnish |
2,401 |
2,372 |
$72K |
| D1120 |
Prophylaxis - child |
736 |
735 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
603 |
594 |
$26K |
| D0274 |
Bitewings - four radiographic images |
1,189 |
1,186 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
2,236 |
2,171 |
$11K |
| D1351 |
Sealant - per tooth |
524 |
66 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,711 |
1,672 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
173 |
173 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
38 |
24 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
98 |
94 |
$2K |
| D0272 |
Bitewings - two radiographic images |
189 |
189 |
$2K |
| D1353 |
|
142 |
15 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
107 |
107 |
$1K |
| D0330 |
Panoramic radiographic image |
24 |
24 |
$960.00 |
| D0601 |
|
56 |
56 |
$560.00 |