| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,980 |
3,936 |
$217K |
| D0120 |
Periodic oral evaluation - established patient |
5,575 |
5,518 |
$127K |
| D0330 |
Panoramic radiographic image |
1,255 |
1,245 |
$114K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,213 |
792 |
$64K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,621 |
873 |
$60K |
| D1351 |
Sealant - per tooth |
3,070 |
609 |
$40K |
| D1120 |
Prophylaxis - child |
2,474 |
2,454 |
$27K |
| D0210 |
Intraoral - complete series of radiographic images |
100 |
100 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
852 |
841 |
$18K |
| D0240 |
|
1,990 |
1,370 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,388 |
6,322 |
$10K |
| D1330 |
|
6,463 |
6,398 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
105 |
87 |
$5K |
| D0274 |
Bitewings - four radiographic images |
2,244 |
2,223 |
$4K |
| D0272 |
Bitewings - two radiographic images |
1,373 |
1,360 |
$2K |
| D0602 |
|
1,079 |
1,073 |
$1K |
| D7111 |
|
18 |
13 |
$646.58 |
| D9999 |
Unspecified adjunctive procedure, by report |
16 |
16 |
$637.30 |
| D0601 |
|
650 |
648 |
$600.70 |
| D0140 |
Limited oral evaluation - problem focused |
30 |
30 |
$407.05 |
| D0220 |
Intraoral - periapical first radiographic image |
39 |
39 |
$15.54 |
| D9993 |
|
110 |
110 |
$0.00 |