| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,155 |
3,141 |
$106K |
| D0120 |
Periodic oral evaluation - established patient |
3,884 |
3,866 |
$90K |
| D1120 |
Prophylaxis - child |
2,227 |
2,215 |
$71K |
| D0330 |
Panoramic radiographic image |
2,004 |
1,982 |
$54K |
| D1206 |
Topical application of fluoride varnish |
2,410 |
2,406 |
$48K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,422 |
1,415 |
$30K |
| D1351 |
Sealant - per tooth |
1,134 |
166 |
$17K |
| D0272 |
Bitewings - two radiographic images |
1,904 |
1,902 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
782 |
776 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
154 |
82 |
$10K |
| D0274 |
Bitewings - four radiographic images |
890 |
881 |
$9K |
| D0603 |
|
818 |
818 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
143 |
140 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
61 |
61 |
$3K |
| D4341 |
|
112 |
43 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
636 |
620 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
45 |
26 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
454 |
448 |
$1K |
| D0602 |
|
44 |
44 |
$430.00 |
| D0190 |
|
12 |
12 |
$120.00 |