| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,264 |
2,263 |
$98K |
| D0120 |
Periodic oral evaluation - established patient |
3,288 |
3,288 |
$82K |
| D1206 |
Topical application of fluoride varnish |
2,082 |
2,081 |
$64K |
| D1120 |
Prophylaxis - child |
1,199 |
1,199 |
$52K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
626 |
368 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
446 |
280 |
$31K |
| D0274 |
Bitewings - four radiographic images |
2,157 |
2,157 |
$26K |
| D0140 |
Limited oral evaluation - problem focused |
363 |
348 |
$16K |
| D0272 |
Bitewings - two radiographic images |
1,237 |
1,237 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
2,202 |
2,112 |
$11K |
| D0330 |
Panoramic radiographic image |
242 |
242 |
$10K |
| D1351 |
Sealant - per tooth |
388 |
75 |
$8K |
| D9920 |
|
234 |
223 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,459 |
1,450 |
$5K |
| D0603 |
|
170 |
170 |
$2K |
| D4355 |
|
14 |
14 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
36 |
36 |
$900.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
25 |
25 |
$625.00 |
| D0602 |
|
41 |
41 |
$410.00 |
| D0601 |
|
27 |
27 |
$260.00 |