| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,770 |
2,769 |
$121K |
| D0120 |
Periodic oral evaluation - established patient |
3,514 |
3,513 |
$86K |
| D0274 |
Bitewings - four radiographic images |
3,643 |
3,642 |
$85K |
| D1120 |
Prophylaxis - child |
1,623 |
1,623 |
$68K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,173 |
4,161 |
$38K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
483 |
448 |
$37K |
| D0220 |
Intraoral - periapical first radiographic image |
4,601 |
4,567 |
$37K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
793 |
793 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
364 |
337 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,440 |
1,440 |
$20K |
| D4341 |
|
197 |
139 |
$16K |
| D1351 |
Sealant - per tooth |
31 |
30 |
$3K |
| D1206 |
Topical application of fluoride varnish |
93 |
93 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
211 |
203 |
$3K |
| D9310 |
|
52 |
52 |
$1K |
| D0272 |
Bitewings - two radiographic images |
37 |
37 |
$470.94 |
| D0240 |
|
16 |
16 |
$312.20 |