| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
840 |
740 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,455 |
1,221 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
724 |
698 |
$15K |
| D1120 |
Prophylaxis - child |
616 |
557 |
$12K |
| D1206 |
Topical application of fluoride varnish |
1,165 |
1,113 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
211 |
141 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
3,359 |
2,564 |
$8K |
| D0274 |
Bitewings - four radiographic images |
1,279 |
1,115 |
$6K |
| D9430 |
|
605 |
537 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
105 |
72 |
$5K |
| D1320 |
|
182 |
182 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,748 |
1,440 |
$2K |
| D1351 |
Sealant - per tooth |
52 |
12 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
110 |
97 |
$2K |
| D0330 |
Panoramic radiographic image |
26 |
26 |
$721.27 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$156.00 |
| D1330 |
|
1,296 |
964 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
577 |
408 |
$0.00 |
| D1310 |
|
89 |
71 |
$0.00 |
| D0603 |
|
14 |
12 |
$0.00 |
| D9993 |
|
77 |
71 |
$0.00 |
| D1203 |
|
15 |
12 |
$0.00 |
| D1999 |
|
24 |
22 |
$0.00 |