| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,288 |
3,285 |
$236K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,716 |
781 |
$89K |
| D1120 |
Prophylaxis - child |
919 |
914 |
$53K |
| D0330 |
Panoramic radiographic image |
507 |
507 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
195 |
195 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
553 |
253 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
79 |
42 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
3,893 |
3,886 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
236 |
232 |
$4K |
| D0274 |
Bitewings - four radiographic images |
2,386 |
2,384 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
206 |
206 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
2,191 |
2,075 |
$623.23 |
| D1351 |
Sealant - per tooth |
415 |
76 |
$366.07 |
| D1206 |
Topical application of fluoride varnish |
2,209 |
2,205 |
$97.17 |
| D0272 |
Bitewings - two radiographic images |
303 |
302 |
$50.18 |
| D1208 |
Topical application of fluoride, excluding varnish |
385 |
385 |
$26.53 |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,281 |
1,009 |
$0.00 |
| D1999 |
|
174 |
169 |
$0.00 |