| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,283 |
2,235 |
$111K |
| D1120 |
Prophylaxis - child |
1,879 |
1,830 |
$82K |
| D0120 |
Periodic oral evaluation - established patient |
3,629 |
3,542 |
$41K |
| D0330 |
Panoramic radiographic image |
455 |
446 |
$39K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
464 |
248 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,986 |
3,892 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
192 |
106 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
313 |
304 |
$3K |
| D0274 |
Bitewings - four radiographic images |
1,713 |
1,679 |
$2K |
| D1351 |
Sealant - per tooth |
266 |
68 |
$1K |
| D1330 |
|
4,126 |
4,025 |
$876.89 |
| D0220 |
Intraoral - periapical first radiographic image |
293 |
287 |
$435.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
233 |
226 |
$348.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
12 |
$126.52 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$13.00 |
| D1999 |
|
140 |
137 |
$0.00 |