| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
919 |
918 |
$5K |
| D1110 |
Prophylaxis - adult |
463 |
462 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
758 |
757 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
106 |
106 |
$1K |
| D1120 |
Prophylaxis - child |
202 |
202 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
612 |
596 |
$984.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
250 |
250 |
$980.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
74 |
27 |
$832.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
47 |
47 |
$811.00 |
| D1351 |
Sealant - per tooth |
540 |
43 |
$642.00 |
| D0274 |
Bitewings - four radiographic images |
165 |
165 |
$495.00 |
| D0272 |
Bitewings - two radiographic images |
142 |
142 |
$344.00 |