| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
662 |
544 |
$14K |
| D2335 |
|
125 |
75 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
1,265 |
1,052 |
$8K |
| D1110 |
Prophylaxis - adult |
922 |
793 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
267 |
227 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,222 |
1,050 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
76 |
39 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
37 |
24 |
$1K |
| D1351 |
Sealant - per tooth |
203 |
27 |
$1K |
| D1330 |
|
1,351 |
1,164 |
$371.23 |
| D9110 |
|
141 |
130 |
$322.04 |
| D0220 |
Intraoral - periapical first radiographic image |
63 |
56 |
$0.00 |