| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,379 |
1,329 |
$68K |
| D1351 |
Sealant - per tooth |
2,337 |
380 |
$60K |
| D0120 |
Periodic oral evaluation - established patient |
2,068 |
1,993 |
$55K |
| D1120 |
Prophylaxis - child |
1,097 |
1,068 |
$38K |
| D0274 |
Bitewings - four radiographic images |
1,126 |
1,092 |
$36K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
325 |
162 |
$30K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,024 |
1,963 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
1,837 |
1,765 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,576 |
1,518 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
172 |
94 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
369 |
350 |
$11K |
| D0330 |
Panoramic radiographic image |
58 |
58 |
$3K |
| D1206 |
Topical application of fluoride varnish |
244 |
233 |
$3K |
| D0272 |
Bitewings - two radiographic images |
102 |
100 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
14 |
14 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
32 |
31 |
$567.14 |
| D0603 |
|
763 |
741 |
$0.00 |
| D0601 |
|
1,970 |
1,918 |
$0.00 |