| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,185 |
1,184 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
1,805 |
1,805 |
$34K |
| D0274 |
Bitewings - four radiographic images |
1,596 |
1,594 |
$29K |
| D1120 |
Prophylaxis - child |
831 |
831 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,010 |
1,010 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
193 |
167 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
446 |
445 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,146 |
1,141 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
653 |
651 |
$4K |
| D0272 |
Bitewings - two radiographic images |
193 |
193 |
$2K |
| D1351 |
Sealant - per tooth |
12 |
12 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
31 |
25 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
71 |
70 |
$835.56 |
| D0270 |
|
13 |
13 |
$98.12 |