| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,281 |
1,260 |
$68K |
| D0274 |
Bitewings - four radiographic images |
1,434 |
1,414 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
973 |
961 |
$23K |
| D0330 |
Panoramic radiographic image |
260 |
252 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
292 |
286 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
557 |
533 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
558 |
409 |
$7K |
| D1120 |
Prophylaxis - child |
67 |
65 |
$3K |
| D1206 |
Topical application of fluoride varnish |
122 |
119 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
29 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
15 |
15 |
$636.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$348.00 |
| D1999 |
|
19 |
17 |
$0.00 |