| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,221 |
1,186 |
$44K |
| D1206 |
Topical application of fluoride varnish |
2,430 |
2,324 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
2,082 |
2,025 |
$37K |
| D4910 |
|
579 |
567 |
$36K |
| D0220 |
Intraoral - periapical first radiographic image |
1,741 |
1,623 |
$18K |
| D0272 |
Bitewings - two radiographic images |
929 |
900 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,337 |
1,139 |
$11K |
| D1120 |
Prophylaxis - child |
239 |
235 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
88 |
65 |
$6K |
| D0330 |
Panoramic radiographic image |
108 |
106 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
92 |
67 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
51 |
50 |
$1K |
| D0603 |
|
476 |
466 |
$1K |
| D0602 |
|
537 |
529 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
41 |
38 |
$958.24 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$191.37 |
| D1999 |
|
1,580 |
1,322 |
$0.00 |