| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,038 |
1,035 |
$75K |
| D1120 |
Prophylaxis - child |
1,124 |
1,124 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
1,914 |
1,910 |
$26K |
| D0274 |
Bitewings - four radiographic images |
1,097 |
1,094 |
$19K |
| D0210 |
Intraoral - complete series of radiographic images |
80 |
80 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
170 |
85 |
$12K |
| D0330 |
Panoramic radiographic image |
134 |
133 |
$11K |
| D1330 |
|
2,290 |
2,287 |
$9K |
| D0272 |
Bitewings - two radiographic images |
776 |
774 |
$6K |
| D1351 |
Sealant - per tooth |
1,369 |
351 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,070 |
1,967 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
66 |
66 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
35 |
25 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,286 |
2,282 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
2,058 |
2,049 |
$622.36 |
| D0240 |
|
163 |
82 |
$321.58 |