| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
7,118 |
7,117 |
$308K |
| D0120 |
Periodic oral evaluation - established patient |
7,291 |
7,290 |
$163K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,598 |
1,153 |
$145K |
| D0274 |
Bitewings - four radiographic images |
5,049 |
5,049 |
$114K |
| D0220 |
Intraoral - periapical first radiographic image |
7,770 |
7,742 |
$95K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,884 |
6,830 |
$69K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,068 |
729 |
$65K |
| D0210 |
Intraoral - complete series of radiographic images |
2,724 |
2,711 |
$57K |
| D1120 |
Prophylaxis - child |
617 |
617 |
$22K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
217 |
190 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,462 |
1,462 |
$18K |
| D1351 |
Sealant - per tooth |
124 |
124 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
582 |
582 |
$13K |
| D2750 |
|
18 |
17 |
$9K |
| D1206 |
Topical application of fluoride varnish |
272 |
272 |
$7K |
| D2335 |
|
12 |
12 |
$2K |
| D2954 |
|
16 |
14 |
$2K |
| D0272 |
Bitewings - two radiographic images |
164 |
164 |
$2K |
| D2330 |
|
28 |
25 |
$2K |
| D2332 |
|
13 |
13 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
123 |
121 |
$1K |
| D4341 |
|
23 |
12 |
$884.46 |
| D2331 |
|
17 |
14 |
$846.51 |