| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,597 |
2,597 |
$97K |
| D0120 |
Periodic oral evaluation - established patient |
3,068 |
3,068 |
$63K |
| D0274 |
Bitewings - four radiographic images |
1,552 |
1,551 |
$31K |
| D1120 |
Prophylaxis - child |
983 |
983 |
$31K |
| D0220 |
Intraoral - periapical first radiographic image |
3,087 |
3,067 |
$31K |
| D0210 |
Intraoral - complete series of radiographic images |
551 |
549 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,484 |
1,484 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,851 |
2,849 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
507 |
506 |
$11K |
| D0272 |
Bitewings - two radiographic images |
716 |
716 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
124 |
72 |
$4K |
| D1351 |
Sealant - per tooth |
13 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
40 |
39 |
$424.38 |
| D1999 |
|
367 |
352 |
$0.00 |