| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
844 |
843 |
$63K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,021 |
506 |
$46K |
| D1120 |
Prophylaxis - child |
407 |
407 |
$35K |
| D0210 |
Intraoral - complete series of radiographic images |
320 |
320 |
$32K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
286 |
199 |
$28K |
| D0140 |
Limited oral evaluation - problem focused |
348 |
345 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
483 |
258 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
588 |
585 |
$5K |
| D1351 |
Sealant - per tooth |
692 |
158 |
$3K |
| D0274 |
Bitewings - four radiographic images |
418 |
418 |
$491.84 |
| D0120 |
Periodic oral evaluation - established patient |
761 |
761 |
$255.90 |
| D0220 |
Intraoral - periapical first radiographic image |
1,046 |
1,027 |
$212.01 |
| D1208 |
Topical application of fluoride, excluding varnish |
1,133 |
1,133 |
$121.30 |
| D0272 |
Bitewings - two radiographic images |
328 |
328 |
$66.56 |
| D0270 |
|
12 |
12 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,167 |
870 |
$0.00 |