| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0601 |
|
608 |
596 |
$31K |
| D1330 |
|
1,266 |
1,224 |
$10K |
| D0603 |
|
240 |
228 |
$8K |
| D1120 |
Prophylaxis - child |
1,036 |
1,003 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
94 |
45 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
936 |
902 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
112 |
111 |
$3K |
| D1110 |
Prophylaxis - adult |
39 |
39 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
718 |
668 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,109 |
1,075 |
$1K |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$1K |
| D1351 |
Sealant - per tooth |
167 |
47 |
$814.68 |
| D0220 |
Intraoral - periapical first radiographic image |
734 |
710 |
$771.39 |
| D0272 |
Bitewings - two radiographic images |
373 |
361 |
$433.24 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
12 |
$335.37 |
| D0274 |
Bitewings - four radiographic images |
40 |
39 |
$17.99 |
| D1206 |
Topical application of fluoride varnish |
44 |
44 |
$0.00 |