| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,333 |
1,331 |
$44K |
| D0274 |
Bitewings - four radiographic images |
1,351 |
1,346 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
1,608 |
1,605 |
$31K |
| D1351 |
Sealant - per tooth |
1,210 |
241 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
402 |
231 |
$22K |
| D1120 |
Prophylaxis - child |
697 |
697 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
959 |
958 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
651 |
650 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
269 |
135 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
1,019 |
1,000 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
135 |
135 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
705 |
590 |
$6K |
| D0272 |
Bitewings - two radiographic images |
255 |
255 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
89 |
87 |
$2K |
| D1999 |
|
17 |
16 |
$0.00 |