| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,070 |
3,068 |
$104K |
| D0274 |
Bitewings - four radiographic images |
3,648 |
3,648 |
$71K |
| D0120 |
Periodic oral evaluation - established patient |
2,312 |
2,311 |
$49K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,975 |
1,975 |
$44K |
| D0220 |
Intraoral - periapical first radiographic image |
4,632 |
4,625 |
$41K |
| D1120 |
Prophylaxis - child |
838 |
835 |
$31K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,934 |
1,933 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,339 |
4,333 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
248 |
207 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
245 |
204 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
939 |
933 |
$6K |
| D1351 |
Sealant - per tooth |
82 |
46 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
120 |
118 |
$1K |
| D0330 |
Panoramic radiographic image |
51 |
51 |
$748.32 |
| D0272 |
Bitewings - two radiographic images |
45 |
45 |
$599.81 |
| D1330 |
|
47 |
46 |
$0.00 |
| D1999 |
|
2,148 |
2,035 |
$0.00 |