| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
622 |
620 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
993 |
990 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
986 |
984 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,034 |
1,031 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
557 |
554 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
69 |
67 |
$5K |
| D1120 |
Prophylaxis - child |
142 |
141 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
297 |
296 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
28 |
$1K |
| D1351 |
Sealant - per tooth |
12 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
88 |
88 |
$1K |
| D0274 |
Bitewings - four radiographic images |
37 |
37 |
$664.10 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
27 |
$540.00 |
| D9110 |
|
32 |
31 |
$409.50 |