| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,303 |
1,217 |
$58K |
| D1206 |
Topical application of fluoride varnish |
2,633 |
2,355 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
1,772 |
1,661 |
$39K |
| D1120 |
Prophylaxis - child |
505 |
472 |
$16K |
| D0274 |
Bitewings - four radiographic images |
444 |
432 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
65 |
38 |
$8K |
| D1310 |
|
402 |
362 |
$8K |
| D0603 |
|
630 |
603 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
163 |
158 |
$5K |
| D1330 |
|
403 |
363 |
$5K |
| D9630 |
|
363 |
337 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
36 |
26 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
108 |
103 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
52 |
51 |
$2K |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$208.30 |
| D0601 |
|
12 |
12 |
$124.40 |
| D1999 |
|
14 |
12 |
$0.00 |