| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
5,689 |
5,627 |
$311K |
| D0120 |
Periodic oral evaluation - established patient |
6,670 |
6,609 |
$158K |
| D0274 |
Bitewings - four radiographic images |
3,225 |
3,188 |
$117K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,990 |
1,981 |
$57K |
| D1120 |
Prophylaxis - child |
672 |
667 |
$33K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
358 |
237 |
$30K |
| D0272 |
Bitewings - two radiographic images |
613 |
608 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
869 |
826 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
174 |
113 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
289 |
286 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
92 |
90 |
$4K |
| D1351 |
Sealant - per tooth |
85 |
25 |
$3K |
| D0330 |
Panoramic radiographic image |
55 |
54 |
$3K |
| D1206 |
Topical application of fluoride varnish |
40 |
40 |
$1K |
| D0180 |
|
19 |
19 |
$768.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
42 |
25 |
$440.00 |
| D1999 |
|
68 |
65 |
$0.00 |