| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,482 |
4,480 |
$193K |
| D0120 |
Periodic oral evaluation - established patient |
6,569 |
6,567 |
$149K |
| D0274 |
Bitewings - four radiographic images |
5,078 |
5,075 |
$115K |
| D1120 |
Prophylaxis - child |
3,015 |
3,013 |
$105K |
| D0220 |
Intraoral - periapical first radiographic image |
7,213 |
7,134 |
$74K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,530 |
6,496 |
$60K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
821 |
537 |
$49K |
| D1351 |
Sealant - per tooth |
789 |
272 |
$40K |
| D0210 |
Intraoral - complete series of radiographic images |
999 |
992 |
$31K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,450 |
2,450 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
696 |
452 |
$27K |
| D1206 |
Topical application of fluoride varnish |
972 |
972 |
$24K |
| D2750 |
|
49 |
42 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
707 |
706 |
$15K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
109 |
93 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
745 |
726 |
$8K |
| D0240 |
|
450 |
431 |
$7K |
| D9310 |
|
118 |
118 |
$5K |
| D0340 |
|
24 |
24 |
$1K |
| D8660 |
|
27 |
27 |
$667.00 |
| D0350 |
|
41 |
41 |
$468.38 |
| D0601 |
|
110 |
110 |
$110.00 |
| D1999 |
|
419 |
387 |
$0.00 |
| D1310 |
|
2,258 |
2,255 |
$0.00 |
| D1330 |
|
2,239 |
2,237 |
$0.00 |