| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,235 |
3,233 |
$134K |
| D0120 |
Periodic oral evaluation - established patient |
4,937 |
4,933 |
$106K |
| D0272 |
Bitewings - two radiographic images |
4,259 |
4,256 |
$52K |
| D1120 |
Prophylaxis - child |
1,559 |
1,555 |
$49K |
| D0220 |
Intraoral - periapical first radiographic image |
5,202 |
5,181 |
$45K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,905 |
2,903 |
$31K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,558 |
2,553 |
$16K |
| D1351 |
Sealant - per tooth |
301 |
70 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
136 |
80 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
73 |
42 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$139.86 |
| D0601 |
|
98 |
98 |
$97.00 |
| D1999 |
|
85 |
85 |
$0.00 |