| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,051 |
4,051 |
$178K |
| D0120 |
Periodic oral evaluation - established patient |
4,529 |
4,529 |
$109K |
| D0274 |
Bitewings - four radiographic images |
3,180 |
3,179 |
$74K |
| D0220 |
Intraoral - periapical first radiographic image |
4,099 |
4,086 |
$61K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
432 |
323 |
$32K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,908 |
1,905 |
$30K |
| D0330 |
Panoramic radiographic image |
1,044 |
1,041 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
752 |
752 |
$14K |
| D1120 |
Prophylaxis - child |
411 |
411 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
887 |
886 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
435 |
435 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
86 |
70 |
$5K |
| D0272 |
Bitewings - two radiographic images |
309 |
309 |
$4K |
| D1351 |
Sealant - per tooth |
90 |
26 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
35 |
25 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
130 |
129 |
$2K |
| D1330 |
|
1,854 |
1,854 |
$0.00 |
| D1999 |
|
508 |
461 |
$0.00 |