| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,511 |
1,460 |
$113K |
| D1120 |
Prophylaxis - child |
1,159 |
1,120 |
$69K |
| D0120 |
Periodic oral evaluation - established patient |
2,593 |
2,501 |
$28K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
180 |
113 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,045 |
1,968 |
$7K |
| D1330 |
|
709 |
661 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
34 |
24 |
$3K |
| D0330 |
Panoramic radiographic image |
47 |
36 |
$3K |
| D8670 |
Periodic orthodontic treatment visit |
28 |
28 |
$1K |
| D1351 |
Sealant - per tooth |
956 |
272 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
2,115 |
2,043 |
$942.95 |
| D1208 |
Topical application of fluoride, excluding varnish |
2,705 |
2,614 |
$380.37 |
| D0274 |
Bitewings - four radiographic images |
1,730 |
1,684 |
$164.72 |
| D0272 |
Bitewings - two radiographic images |
692 |
668 |
$107.64 |
| D3120 |
|
21 |
12 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
16 |
13 |
$0.00 |