| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,096 |
998 |
$56K |
| D0120 |
Periodic oral evaluation - established patient |
1,496 |
1,356 |
$38K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,451 |
1,298 |
$30K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
167 |
80 |
$16K |
| D1351 |
Sealant - per tooth |
455 |
41 |
$12K |
| D1120 |
Prophylaxis - child |
223 |
199 |
$10K |
| D0274 |
Bitewings - four radiographic images |
255 |
229 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
120 |
93 |
$4K |
| D0330 |
Panoramic radiographic image |
50 |
40 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
160 |
134 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
107 |
69 |
$882.48 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$462.00 |
| D1999 |
|
38 |
28 |
$0.00 |