| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,055 |
1,936 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
2,741 |
2,551 |
$2K |
| D0274 |
Bitewings - four radiographic images |
1,475 |
1,400 |
$2K |
| D1206 |
Topical application of fluoride varnish |
2,808 |
2,643 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
260 |
203 |
$1K |
| D1120 |
Prophylaxis - child |
738 |
691 |
$815.83 |
| D0220 |
Intraoral - periapical first radiographic image |
1,141 |
1,057 |
$524.88 |
| D0140 |
Limited oral evaluation - problem focused |
596 |
552 |
$455.00 |
| D0603 |
|
3,522 |
3,177 |
$278.46 |
| D0230 |
Intraoral - periapical each additional radiographic image |
640 |
323 |
$196.00 |
| D1330 |
|
5,116 |
4,698 |
$196.00 |
| D0602 |
|
778 |
702 |
$190.00 |
| D0601 |
|
218 |
195 |
$0.00 |
| D1320 |
|
38 |
28 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
150 |
141 |
$0.00 |
| D1351 |
Sealant - per tooth |
36 |
13 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$0.00 |
| D1354 |
|
518 |
250 |
$0.00 |
| D2940 |
|
235 |
155 |
$0.00 |