| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
959 |
734 |
$26K |
| D0274 |
Bitewings - four radiographic images |
897 |
658 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
1,104 |
838 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
598 |
448 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
259 |
211 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
359 |
264 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
838 |
529 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
393 |
319 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
58 |
26 |
$3K |
| D0330 |
Panoramic radiographic image |
192 |
132 |
$2K |
| D1206 |
Topical application of fluoride varnish |
107 |
57 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
189 |
67 |
$1K |
| D1120 |
Prophylaxis - child |
75 |
66 |
$793.50 |
| D1351 |
Sealant - per tooth |
56 |
12 |
$205.45 |
| D1999 |
|
382 |
188 |
$0.00 |