| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,307 |
3,301 |
$139K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,597 |
970 |
$131K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,050 |
1,196 |
$120K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,065 |
2,060 |
$48K |
| D0120 |
Periodic oral evaluation - established patient |
2,015 |
2,013 |
$43K |
| D9310 |
|
399 |
399 |
$23K |
| D0274 |
Bitewings - four radiographic images |
933 |
929 |
$19K |
| D1120 |
Prophylaxis - child |
484 |
483 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
714 |
698 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
402 |
401 |
$5K |
| D1351 |
Sealant - per tooth |
42 |
27 |
$3K |
| D0330 |
Panoramic radiographic image |
79 |
79 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
257 |
255 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
73 |
72 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
74 |
73 |
$803.88 |
| D9110 |
|
14 |
14 |
$241.02 |
| D1330 |
|
14 |
14 |
$0.00 |