| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,262 |
3,204 |
$176K |
| D0220 |
Intraoral - periapical first radiographic image |
6,470 |
5,953 |
$100K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,433 |
823 |
$99K |
| D0120 |
Periodic oral evaluation - established patient |
4,037 |
3,970 |
$97K |
| D0274 |
Bitewings - four radiographic images |
2,466 |
2,422 |
$90K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,092 |
639 |
$90K |
| D0140 |
Limited oral evaluation - problem focused |
2,293 |
2,192 |
$89K |
| D2331 |
|
735 |
461 |
$62K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,241 |
3,867 |
$56K |
| D2330 |
|
411 |
276 |
$28K |
| D1120 |
Prophylaxis - child |
551 |
545 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
710 |
706 |
$21K |
| D1206 |
Topical application of fluoride varnish |
445 |
441 |
$11K |
| D9110 |
|
189 |
184 |
$7K |
| D1351 |
Sealant - per tooth |
106 |
33 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
74 |
73 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
22 |
13 |
$2K |
| D2332 |
|
15 |
13 |
$2K |
| D1330 |
|
278 |
275 |
$910.00 |
| D3120 |
|
18 |
13 |
$624.00 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$390.00 |
| D9450 |
|
15 |
14 |
$0.00 |