| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,313 |
2,305 |
$149K |
| D0120 |
Periodic oral evaluation - established patient |
3,337 |
3,328 |
$114K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
997 |
997 |
$87K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
446 |
289 |
$34K |
| D0240 |
|
1,195 |
760 |
$19K |
| D1120 |
Prophylaxis - child |
2,005 |
2,004 |
$18K |
| D9999 |
Unspecified adjunctive procedure, by report |
255 |
253 |
$14K |
| D1351 |
Sealant - per tooth |
4,203 |
828 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
478 |
268 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,715 |
3,706 |
$8K |
| D1330 |
|
4,391 |
4,382 |
$6K |
| D0274 |
Bitewings - four radiographic images |
2,647 |
2,639 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
116 |
115 |
$2K |
| D1206 |
Topical application of fluoride varnish |
578 |
578 |
$2K |
| D0272 |
Bitewings - two radiographic images |
976 |
976 |
$1K |
| D0601 |
|
501 |
501 |
$596.02 |
| D0602 |
|
208 |
208 |
$185.74 |
| D0603 |
|
186 |
186 |
$164.00 |
| D0220 |
Intraoral - periapical first radiographic image |
291 |
285 |
$29.95 |