| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,003 |
986 |
$53K |
| D0120 |
Periodic oral evaluation - established patient |
625 |
619 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
891 |
876 |
$21K |
| D0330 |
Panoramic radiographic image |
638 |
623 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,534 |
1,791 |
$4K |
| D0272 |
Bitewings - two radiographic images |
1,311 |
1,291 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,542 |
1,518 |
$4K |
| D1120 |
Prophylaxis - child |
338 |
334 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
2,107 |
2,066 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
63 |
26 |
$2K |
| D1351 |
Sealant - per tooth |
79 |
15 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
156 |
146 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
12 |
$1K |
| D1330 |
|
1,500 |
1,473 |
$610.00 |