| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,635 |
3,635 |
$154K |
| D0120 |
Periodic oral evaluation - established patient |
3,490 |
3,489 |
$76K |
| D0210 |
Intraoral - complete series of radiographic images |
3,294 |
3,272 |
$69K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,344 |
3,331 |
$59K |
| D0220 |
Intraoral - periapical first radiographic image |
4,071 |
4,043 |
$46K |
| D1120 |
Prophylaxis - child |
1,012 |
1,011 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,248 |
1,248 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,986 |
1,984 |
$23K |
| D0274 |
Bitewings - four radiographic images |
836 |
834 |
$16K |
| D4341 |
|
316 |
147 |
$14K |
| D1351 |
Sealant - per tooth |
221 |
102 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
179 |
141 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
132 |
75 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
65 |
52 |
$4K |
| D0272 |
Bitewings - two radiographic images |
94 |
94 |
$1K |
| D0330 |
Panoramic radiographic image |
16 |
16 |
$391.68 |
| D0140 |
Limited oral evaluation - problem focused |
26 |
25 |
$231.45 |
| D1320 |
|
32 |
32 |
$170.86 |
| D1330 |
|
12 |
12 |
$0.00 |
| D1999 |
|
34 |
31 |
$0.00 |