| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
765 |
666 |
$24K |
| D0330 |
Panoramic radiographic image |
404 |
354 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
859 |
756 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
618 |
535 |
$8K |
| D1351 |
Sealant - per tooth |
429 |
65 |
$5K |
| D0274 |
Bitewings - four radiographic images |
195 |
177 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
151 |
138 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
38 |
12 |
$2K |
| D1120 |
Prophylaxis - child |
52 |
47 |
$621.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
21 |
18 |
$163.30 |
| D1999 |
|
29 |
17 |
$0.00 |