| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
384 |
373 |
$19K |
| D1120 |
Prophylaxis - child |
501 |
489 |
$17K |
| D1206 |
Topical application of fluoride varnish |
1,162 |
1,134 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
194 |
125 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
701 |
670 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,035 |
413 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
229 |
219 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
52 |
41 |
$5K |
| D0330 |
Panoramic radiographic image |
178 |
171 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
134 |
130 |
$4K |
| D0274 |
Bitewings - four radiographic images |
125 |
124 |
$3K |
| D0272 |
Bitewings - two radiographic images |
14 |
13 |
$273.54 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$207.55 |
| D1330 |
|
73 |
71 |
$20.00 |
| D0603 |
|
1,103 |
1,060 |
$0.00 |