| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,315 |
1,293 |
$103K |
| D0603 |
|
203 |
203 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
134 |
132 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
96 |
96 |
$11K |
| D1120 |
Prophylaxis - child |
676 |
669 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
33 |
31 |
$4K |
| D1206 |
Topical application of fluoride varnish |
589 |
584 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
14 |
13 |
$2K |
| D1110 |
Prophylaxis - adult |
120 |
119 |
$1K |
| D0601 |
|
27 |
27 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
30 |
29 |
$0.00 |
| D1330 |
|
12 |
12 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
37 |
37 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
45 |
44 |
$0.00 |
| D0330 |
Panoramic radiographic image |
14 |
13 |
$0.00 |