| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,090 |
1,082 |
$77K |
| D1110 |
Prophylaxis - adult |
1,708 |
1,694 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
1,768 |
1,750 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
468 |
206 |
$27K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
296 |
130 |
$25K |
| D1120 |
Prophylaxis - child |
956 |
943 |
$20K |
| D0330 |
Panoramic radiographic image |
657 |
650 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,616 |
2,590 |
$4K |
| D1351 |
Sealant - per tooth |
1,379 |
268 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
2,754 |
2,685 |
$4K |
| D3120 |
|
1,007 |
359 |
$2K |
| D0274 |
Bitewings - four radiographic images |
1,617 |
1,603 |
$2K |
| D1330 |
|
2,561 |
2,535 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,596 |
2,535 |
$998.77 |
| D0140 |
Limited oral evaluation - problem focused |
104 |
100 |
$904.13 |
| D0272 |
Bitewings - two radiographic images |
798 |
785 |
$666.90 |
| D9986 |
|
16 |
16 |
$0.00 |