| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,514 |
1,477 |
$64K |
| D1206 |
Topical application of fluoride varnish |
1,675 |
1,631 |
$34K |
| D0330 |
Panoramic radiographic image |
723 |
704 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
953 |
932 |
$23K |
| D0274 |
Bitewings - four radiographic images |
778 |
754 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,220 |
1,167 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
501 |
482 |
$14K |
| D1120 |
Prophylaxis - child |
373 |
354 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,060 |
957 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
379 |
366 |
$8K |
| D1351 |
Sealant - per tooth |
225 |
51 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
81 |
39 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
52 |
25 |
$4K |
| D2140 |
|
32 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
12 |
$144.96 |
| D1999 |
|
71 |
61 |
$0.00 |