| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,075 |
4,065 |
$178K |
| D0120 |
Periodic oral evaluation - established patient |
4,748 |
4,740 |
$106K |
| D0274 |
Bitewings - four radiographic images |
3,604 |
3,604 |
$80K |
| D0220 |
Intraoral - periapical first radiographic image |
5,374 |
5,357 |
$57K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,056 |
5,055 |
$56K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
823 |
572 |
$48K |
| D1120 |
Prophylaxis - child |
1,331 |
1,331 |
$42K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
379 |
315 |
$31K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,554 |
2,554 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
502 |
502 |
$11K |
| D0272 |
Bitewings - two radiographic images |
630 |
630 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
153 |
153 |
$6K |
| D1351 |
Sealant - per tooth |
12 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
41 |
41 |
$415.27 |
| D1206 |
Topical application of fluoride varnish |
16 |
16 |
$385.00 |
| D1999 |
|
216 |
211 |
$0.00 |