| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
742 |
741 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
1,363 |
1,361 |
$36K |
| D1351 |
Sealant - per tooth |
1,105 |
140 |
$33K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
240 |
122 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
632 |
632 |
$15K |
| D1120 |
Prophylaxis - child |
381 |
381 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
881 |
866 |
$13K |
| D0274 |
Bitewings - four radiographic images |
397 |
397 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
333 |
313 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
791 |
717 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
76 |
40 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
82 |
81 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$480.00 |