| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,643 |
1,614 |
$62K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,832 |
2,801 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
2,856 |
2,823 |
$48K |
| D1120 |
Prophylaxis - child |
1,531 |
1,515 |
$45K |
| D9630 |
|
1,709 |
1,704 |
$27K |
| D0272 |
Bitewings - two radiographic images |
1,309 |
1,282 |
$22K |
| D9920 |
|
269 |
244 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
94 |
40 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
240 |
220 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
98 |
24 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
84 |
36 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
44 |
40 |
$2K |
| D0330 |
Panoramic radiographic image |
19 |
12 |
$539.90 |
| D0220 |
Intraoral - periapical first radiographic image |
73 |
67 |
$134.16 |
| D0274 |
Bitewings - four radiographic images |
43 |
43 |
$0.00 |
| D1351 |
Sealant - per tooth |
86 |
24 |
$0.00 |