| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,411 |
3,409 |
$117K |
| D0120 |
Periodic oral evaluation - established patient |
4,120 |
4,114 |
$80K |
| D0210 |
Intraoral - complete series of radiographic images |
1,679 |
1,677 |
$56K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
677 |
229 |
$44K |
| D0274 |
Bitewings - four radiographic images |
1,618 |
1,618 |
$30K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
330 |
233 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
539 |
290 |
$24K |
| D2952 |
|
188 |
159 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
2,020 |
2,019 |
$18K |
| D9945 |
|
223 |
223 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,992 |
1,991 |
$12K |
| D2750 |
|
28 |
25 |
$10K |
| D1206 |
Topical application of fluoride varnish |
219 |
219 |
$5K |
| D1120 |
Prophylaxis - child |
160 |
160 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
148 |
148 |
$3K |
| D0330 |
Panoramic radiographic image |
65 |
65 |
$2K |
| D1351 |
Sealant - per tooth |
15 |
12 |
$2K |
| D9110 |
|
113 |
110 |
$2K |
| D9995 |
|
30 |
30 |
$704.40 |
| D0140 |
Limited oral evaluation - problem focused |
54 |
54 |
$552.30 |
| D0272 |
Bitewings - two radiographic images |
25 |
25 |
$315.73 |
| D0240 |
|
21 |
21 |
$10.00 |