| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,124 |
2,120 |
$211K |
| D1120 |
Prophylaxis - child |
587 |
586 |
$52K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
196 |
85 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
56 |
55 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
26 |
26 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
2,533 |
2,530 |
$606.80 |
| D0274 |
Bitewings - four radiographic images |
1,792 |
1,791 |
$353.76 |
| D1351 |
Sealant - per tooth |
279 |
36 |
$187.47 |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,797 |
2,659 |
$95.24 |
| D0220 |
Intraoral - periapical first radiographic image |
2,768 |
2,725 |
$78.86 |
| D1208 |
Topical application of fluoride, excluding varnish |
2,401 |
2,398 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
348 |
347 |
$0.00 |