| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,776 |
2,689 |
$147K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,105 |
701 |
$91K |
| D0274 |
Bitewings - four radiographic images |
1,749 |
1,694 |
$63K |
| D0120 |
Periodic oral evaluation - established patient |
2,519 |
2,449 |
$60K |
| D0210 |
Intraoral - complete series of radiographic images |
618 |
595 |
$44K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
681 |
658 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
943 |
928 |
$28K |
| D1120 |
Prophylaxis - child |
478 |
470 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
266 |
158 |
$17K |
| D8670 |
Periodic orthodontic treatment visit |
55 |
55 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
389 |
370 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
487 |
459 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
74 |
58 |
$7K |
| D0330 |
Panoramic radiographic image |
131 |
116 |
$5K |
| D1351 |
Sealant - per tooth |
103 |
25 |
$4K |
| D4341 |
|
25 |
13 |
$3K |
| D8690 |
|
21 |
20 |
$3K |
| D8660 |
|
34 |
30 |
$2K |
| D2331 |
|
21 |
13 |
$2K |
| D0272 |
Bitewings - two radiographic images |
40 |
39 |
$1K |
| D9310 |
|
18 |
12 |
$756.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
19 |
14 |
$259.00 |
| D1999 |
|
114 |
103 |
$0.00 |