| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,175 |
2,171 |
$166K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,774 |
976 |
$107K |
| D1120 |
Prophylaxis - child |
276 |
276 |
$14K |
| D0330 |
Panoramic radiographic image |
233 |
231 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
101 |
71 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
536 |
324 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
902 |
893 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
118 |
118 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
425 |
424 |
$7K |
| D4341 |
|
82 |
32 |
$5K |
| D0274 |
Bitewings - four radiographic images |
1,720 |
1,717 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
2,331 |
2,329 |
$550.30 |
| D1351 |
Sealant - per tooth |
375 |
77 |
$499.92 |
| D0220 |
Intraoral - periapical first radiographic image |
974 |
941 |
$467.32 |
| D0230 |
Intraoral - periapical each additional radiographic image |
823 |
630 |
$64.54 |
| D1208 |
Topical application of fluoride, excluding varnish |
1,549 |
1,547 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
30 |
30 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
39 |
39 |
$0.00 |