| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9110 |
|
2,029 |
1,941 |
$105K |
| D1120 |
Prophylaxis - child |
1,365 |
1,305 |
$54K |
| D0120 |
Periodic oral evaluation - established patient |
1,925 |
1,834 |
$52K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
604 |
453 |
$50K |
| D1206 |
Topical application of fluoride varnish |
1,147 |
1,094 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
982 |
927 |
$22K |
| D4341 |
|
122 |
57 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
2,852 |
2,629 |
$17K |
| D0274 |
Bitewings - four radiographic images |
973 |
938 |
$16K |
| D1110 |
Prophylaxis - adult |
367 |
338 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,692 |
1,571 |
$7K |
| D1351 |
Sealant - per tooth |
64 |
29 |
$5K |
| D0272 |
Bitewings - two radiographic images |
558 |
510 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
211 |
202 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
30 |
30 |
$910.30 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
12 |
12 |
$674.10 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14 |
12 |
$524.45 |