| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,167 |
4,167 |
$226K |
| D0120 |
Periodic oral evaluation - established patient |
4,869 |
4,865 |
$135K |
| D1120 |
Prophylaxis - child |
3,002 |
3,001 |
$127K |
| D0274 |
Bitewings - four radiographic images |
3,081 |
3,081 |
$85K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,358 |
4,354 |
$73K |
| D1351 |
Sealant - per tooth |
972 |
461 |
$73K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,385 |
2,385 |
$70K |
| D0210 |
Intraoral - complete series of radiographic images |
1,079 |
1,079 |
$53K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,085 |
3,084 |
$43K |
| D0220 |
Intraoral - periapical first radiographic image |
3,122 |
3,119 |
$42K |
| D0272 |
Bitewings - two radiographic images |
1,441 |
1,440 |
$23K |
| D1206 |
Topical application of fluoride varnish |
690 |
690 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
118 |
95 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
12 |
$2K |
| D1999 |
|
34 |
33 |
$0.00 |