| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,833 |
1,759 |
$61K |
| D0120 |
Periodic oral evaluation - established patient |
2,172 |
2,090 |
$34K |
| D1206 |
Topical application of fluoride varnish |
2,377 |
2,289 |
$34K |
| D0274 |
Bitewings - four radiographic images |
926 |
881 |
$21K |
| D2752 |
|
48 |
27 |
$12K |
| D1120 |
Prophylaxis - child |
423 |
401 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
342 |
321 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
874 |
756 |
$8K |
| D1351 |
Sealant - per tooth |
450 |
48 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
234 |
226 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
80 |
80 |
$4K |
| D0603 |
|
439 |
430 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
15 |
$1K |
| D4910 |
|
12 |
12 |
$711.33 |
| D0230 |
Intraoral - periapical each additional radiographic image |
49 |
28 |
$364.02 |