| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,053 |
1,050 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
912 |
906 |
$24K |
| D1120 |
Prophylaxis - child |
1,285 |
1,275 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
434 |
250 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
1,365 |
1,360 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,572 |
1,559 |
$22K |
| D0274 |
Bitewings - four radiographic images |
711 |
705 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
207 |
112 |
$10K |
| D2335 |
|
18 |
12 |
$2K |
| D1351 |
Sealant - per tooth |
72 |
25 |
$1K |
| D0272 |
Bitewings - two radiographic images |
121 |
120 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
41 |
38 |
$925.78 |
| D0220 |
Intraoral - periapical first radiographic image |
149 |
133 |
$695.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
49 |
13 |
$235.00 |