| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,651 |
1,617 |
$65K |
| D0330 |
Panoramic radiographic image |
955 |
881 |
$38K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,227 |
1,086 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,323 |
1,319 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
1,352 |
1,339 |
$21K |
| D1120 |
Prophylaxis - child |
661 |
659 |
$20K |
| D9920 |
|
304 |
300 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
209 |
129 |
$18K |
| D9992 |
|
2,691 |
2,274 |
$16K |
| D9994 |
|
2,559 |
2,168 |
$15K |
| D0274 |
Bitewings - four radiographic images |
571 |
561 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
863 |
663 |
$13K |
| D9630 |
|
637 |
629 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
123 |
52 |
$8K |
| D9110 |
|
89 |
89 |
$3K |
| D0170 |
|
134 |
82 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
12 |
$2K |
| D9995 |
|
68 |
38 |
$1K |
| D1351 |
Sealant - per tooth |
43 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
180 |
171 |
$1K |
| D3120 |
|
47 |
25 |
$430.74 |
| D9999 |
Unspecified adjunctive procedure, by report |
340 |
268 |
$183.00 |
| D4355 |
|
26 |
26 |
$0.00 |
| D0190 |
|
319 |
254 |
$0.00 |
| D1999 |
|
314 |
250 |
$0.00 |