| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,998 |
1,882 |
$75K |
| D1110 |
Prophylaxis - adult |
1,511 |
1,407 |
$40K |
| D4341 |
|
209 |
130 |
$39K |
| D0274 |
Bitewings - four radiographic images |
1,554 |
1,459 |
$26K |
| D1206 |
Topical application of fluoride varnish |
965 |
883 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
643 |
588 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
2,464 |
2,297 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,271 |
2,113 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
276 |
258 |
$6K |
| D0272 |
Bitewings - two radiographic images |
349 |
334 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
79 |
79 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
31 |
25 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
76 |
75 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
41 |
40 |
$664.20 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$75.40 |
| D1330 |
|
120 |
113 |
$0.00 |