| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,940 |
2,939 |
$127K |
| D0120 |
Periodic oral evaluation - established patient |
3,715 |
3,715 |
$81K |
| D0274 |
Bitewings - four radiographic images |
3,135 |
3,135 |
$67K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,202 |
4,192 |
$45K |
| D1120 |
Prophylaxis - child |
1,363 |
1,362 |
$43K |
| D0220 |
Intraoral - periapical first radiographic image |
4,181 |
4,174 |
$43K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
434 |
335 |
$30K |
| D0210 |
Intraoral - complete series of radiographic images |
2,762 |
2,756 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,687 |
1,687 |
$18K |
| D0350 |
|
1,458 |
1,458 |
$15K |
| D1206 |
Topical application of fluoride varnish |
522 |
522 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
481 |
481 |
$11K |
| D1351 |
Sealant - per tooth |
151 |
105 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
130 |
114 |
$7K |
| D2752 |
|
12 |
12 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
34 |
28 |
$2K |
| D0272 |
Bitewings - two radiographic images |
52 |
52 |
$661.18 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$124.36 |
| D1999 |
|
35 |
35 |
$0.00 |
| D0999 |
Unspecified diagnostic procedure, by report |
95 |
92 |
$0.00 |