| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
883 |
876 |
$66K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,024 |
625 |
$63K |
| D0120 |
Periodic oral evaluation - established patient |
840 |
836 |
$41K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
870 |
865 |
$36K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
197 |
140 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
663 |
394 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,741 |
1,664 |
$16K |
| D0274 |
Bitewings - four radiographic images |
1,695 |
1,685 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,451 |
1,444 |
$11K |
| D1120 |
Prophylaxis - child |
698 |
695 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
1,833 |
1,814 |
$4K |
| D1330 |
|
1,488 |
1,480 |
$3K |
| D9999 |
Unspecified adjunctive procedure, by report |
30 |
30 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
20 |
20 |
$1K |
| D1351 |
Sealant - per tooth |
106 |
26 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
49 |
47 |
$643.12 |
| D0601 |
|
509 |
509 |
$182.00 |
| D0602 |
|
49 |
49 |
$25.00 |