| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9211 |
|
272 |
155 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,269 |
688 |
$13K |
| D0330 |
Panoramic radiographic image |
261 |
212 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,127 |
913 |
$10K |
| D0274 |
Bitewings - four radiographic images |
421 |
383 |
$10K |
| D1110 |
Prophylaxis - adult |
150 |
139 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
240 |
196 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
97 |
95 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
12 |
$2K |
| D1206 |
Topical application of fluoride varnish |
109 |
105 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
44 |
41 |
$1K |
| D1120 |
Prophylaxis - child |
15 |
15 |
$690.64 |
| D0350 |
|
279 |
138 |
$498.16 |
| D1330 |
|
198 |
187 |
$165.78 |
| D0431 |
|
198 |
188 |
$0.00 |