| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,462 |
2,434 |
$83K |
| D0120 |
Periodic oral evaluation - established patient |
4,154 |
4,103 |
$81K |
| D1120 |
Prophylaxis - child |
1,780 |
1,760 |
$53K |
| D0274 |
Bitewings - four radiographic images |
2,131 |
2,120 |
$40K |
| D0220 |
Intraoral - periapical first radiographic image |
3,952 |
3,929 |
$39K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,969 |
3,950 |
$30K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,209 |
2,189 |
$23K |
| D0272 |
Bitewings - two radiographic images |
1,203 |
1,200 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
227 |
201 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
137 |
119 |
$8K |
| D0330 |
Panoramic radiographic image |
232 |
230 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
305 |
303 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
86 |
85 |
$2K |
| D1351 |
Sealant - per tooth |
16 |
13 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
50 |
48 |
$376.42 |
| D9110 |
|
25 |
25 |
$314.28 |