| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,014 |
997 |
$48K |
| D0120 |
Periodic oral evaluation - established patient |
1,457 |
1,428 |
$45K |
| D0230 |
Intraoral - periapical each additional radiographic image |
890 |
641 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
817 |
792 |
$12K |
| D0274 |
Bitewings - four radiographic images |
379 |
376 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
466 |
455 |
$9K |
| D1120 |
Prophylaxis - child |
202 |
200 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
70 |
40 |
$7K |
| D0330 |
Panoramic radiographic image |
69 |
69 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
41 |
40 |
$1K |
| D1351 |
Sealant - per tooth |
39 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$288.00 |
| D0240 |
|
22 |
13 |
$195.00 |
| D1206 |
Topical application of fluoride varnish |
14 |
12 |
$43.26 |
| D9211 |
|
52 |
28 |
$0.00 |