| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,619 |
1,609 |
$114K |
| D1110 |
Prophylaxis - adult |
1,431 |
1,417 |
$114K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
840 |
427 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
2,226 |
2,208 |
$40K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
147 |
95 |
$12K |
| D1351 |
Sealant - per tooth |
2,598 |
637 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,918 |
2,952 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
609 |
591 |
$6K |
| D0330 |
Panoramic radiographic image |
109 |
109 |
$4K |
| D0190 |
|
1,985 |
1,962 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
73 |
72 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
2,991 |
2,954 |
$2K |
| D0350 |
|
732 |
723 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,082 |
3,056 |
$736.40 |
| D9999 |
Unspecified adjunctive procedure, by report |
31 |
31 |
$705.00 |
| D9215 |
|
18 |
18 |
$588.91 |
| D1999 |
|
1,652 |
1,636 |
$560.00 |
| D1330 |
|
3,136 |
3,111 |
$544.93 |
| D0601 |
|
2,661 |
2,632 |
$467.57 |
| D1206 |
Topical application of fluoride varnish |
40 |
40 |
$162.80 |
| D0272 |
Bitewings - two radiographic images |
1,776 |
1,761 |
$95.00 |
| D0274 |
Bitewings - four radiographic images |
103 |
101 |
$0.00 |
| D9995 |
|
16 |
16 |
$0.00 |
| D0602 |
|
16 |
16 |
$0.00 |