| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,304 |
1,304 |
$72K |
| D0120 |
Periodic oral evaluation - established patient |
1,788 |
1,788 |
$50K |
| D1120 |
Prophylaxis - child |
753 |
753 |
$32K |
| D0274 |
Bitewings - four radiographic images |
1,044 |
1,044 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
960 |
960 |
$13K |
| D0272 |
Bitewings - two radiographic images |
435 |
435 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
63 |
58 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
276 |
272 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
111 |
111 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
38 |
37 |
$3K |
| D1351 |
Sealant - per tooth |
13 |
13 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
25 |
25 |
$1K |
| D1999 |
|
262 |
245 |
$0.00 |