| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,965 |
3,766 |
$205K |
| D0120 |
Periodic oral evaluation - established patient |
5,497 |
5,232 |
$148K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
728 |
524 |
$94K |
| D1120 |
Prophylaxis - child |
1,886 |
1,814 |
$72K |
| D1206 |
Topical application of fluoride varnish |
2,604 |
2,501 |
$54K |
| D0274 |
Bitewings - four radiographic images |
1,571 |
1,514 |
$52K |
| D0140 |
Limited oral evaluation - problem focused |
1,065 |
964 |
$44K |
| D0272 |
Bitewings - two radiographic images |
783 |
760 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
70 |
51 |
$6K |
| D2335 |
|
13 |
12 |
$2K |
| D1351 |
Sealant - per tooth |
57 |
13 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
28 |
27 |
$1K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$660.00 |
| D0220 |
Intraoral - periapical first radiographic image |
29 |
29 |
$459.00 |
| D9987 |
|
1,002 |
980 |
$0.00 |
| D9986 |
|
15 |
15 |
$0.00 |