| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,141 |
1,119 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
1,030 |
1,011 |
$19K |
| D1120 |
Prophylaxis - child |
331 |
329 |
$12K |
| D0274 |
Bitewings - four radiographic images |
694 |
681 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
445 |
444 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
352 |
345 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
171 |
162 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
64 |
42 |
$4K |
| D0330 |
Panoramic radiographic image |
103 |
103 |
$4K |
| D1351 |
Sealant - per tooth |
100 |
13 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
512 |
493 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
482 |
212 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
14 |
$875.00 |
| D9110 |
|
13 |
13 |
$408.00 |
| D1206 |
Topical application of fluoride varnish |
31 |
31 |
$0.00 |