| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
596 |
576 |
$32K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,074 |
1,045 |
$27K |
| D1351 |
Sealant - per tooth |
658 |
118 |
$25K |
| D0210 |
Intraoral - complete series of radiographic images |
298 |
286 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
557 |
530 |
$20K |
| D1120 |
Prophylaxis - child |
377 |
370 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
486 |
484 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
722 |
698 |
$10K |
| D0274 |
Bitewings - four radiographic images |
247 |
247 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
66 |
41 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
627 |
492 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
57 |
27 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
58 |
52 |
$2K |
| D0272 |
Bitewings - two radiographic images |
27 |
27 |
$527.59 |
| D8670 |
Periodic orthodontic treatment visit |
15 |
15 |
$0.00 |