| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,090 |
3,090 |
$113K |
| D0120 |
Periodic oral evaluation - established patient |
3,793 |
3,792 |
$76K |
| D1120 |
Prophylaxis - child |
2,334 |
2,332 |
$75K |
| D0274 |
Bitewings - four radiographic images |
2,819 |
2,819 |
$56K |
| D0220 |
Intraoral - periapical first radiographic image |
4,441 |
4,408 |
$37K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,366 |
1,365 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
384 |
331 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,960 |
1,958 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,971 |
3,943 |
$18K |
| D1206 |
Topical application of fluoride varnish |
741 |
741 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
351 |
285 |
$15K |
| D0272 |
Bitewings - two radiographic images |
1,004 |
1,003 |
$12K |
| D1351 |
Sealant - per tooth |
47 |
28 |
$3K |
| D9110 |
|
66 |
65 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
84 |
84 |
$765.83 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$367.90 |