| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
428 |
351 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
647 |
546 |
$7K |
| D1120 |
Prophylaxis - child |
385 |
331 |
$6K |
| D0274 |
Bitewings - four radiographic images |
491 |
408 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
989 |
815 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
546 |
462 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,177 |
683 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
240 |
206 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
102 |
56 |
$3K |
| D0272 |
Bitewings - two radiographic images |
263 |
219 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
119 |
98 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
41 |
24 |
$1K |
| D1351 |
Sealant - per tooth |
84 |
17 |
$1K |
| D0270 |
|
69 |
57 |
$343.26 |
| D1999 |
|
163 |
151 |
$0.00 |