| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,067 |
4,066 |
$144K |
| D0120 |
Periodic oral evaluation - established patient |
4,900 |
4,899 |
$101K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,834 |
4,810 |
$61K |
| D0220 |
Intraoral - periapical first radiographic image |
5,376 |
5,362 |
$50K |
| D0210 |
Intraoral - complete series of radiographic images |
3,057 |
3,012 |
$45K |
| D0274 |
Bitewings - four radiographic images |
1,407 |
1,407 |
$31K |
| D1120 |
Prophylaxis - child |
725 |
725 |
$29K |
| D1206 |
Topical application of fluoride varnish |
620 |
620 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,017 |
1,017 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
249 |
154 |
$13K |
| D1351 |
Sealant - per tooth |
108 |
28 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
82 |
51 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
105 |
67 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
86 |
86 |
$2K |
| D0470 |
|
81 |
81 |
$2K |
| D9310 |
|
25 |
25 |
$1K |
| D4341 |
|
42 |
12 |
$1K |
| D9990 |
|
41 |
41 |
$858.00 |