| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0240 |
|
3,816 |
1,551 |
$40K |
| D1110 |
Prophylaxis - adult |
944 |
878 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
785 |
749 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
1,177 |
1,049 |
$18K |
| D0210 |
Intraoral - complete series of radiographic images |
338 |
329 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,031 |
979 |
$16K |
| D0274 |
Bitewings - four radiographic images |
778 |
699 |
$15K |
| D1120 |
Prophylaxis - child |
725 |
683 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
469 |
400 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
180 |
91 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
106 |
65 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
539 |
441 |
$2K |
| D0272 |
Bitewings - two radiographic images |
138 |
131 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
280 |
216 |
$1K |
| D0330 |
Panoramic radiographic image |
25 |
24 |
$1K |
| D1351 |
Sealant - per tooth |
41 |
12 |
$947.10 |
| D1320 |
|
13 |
13 |
$204.75 |