| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
6,018 |
6,017 |
$208K |
| D0330 |
Panoramic radiographic image |
4,871 |
4,871 |
$100K |
| D0120 |
Periodic oral evaluation - established patient |
4,533 |
4,531 |
$90K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,172 |
3,172 |
$69K |
| D1120 |
Prophylaxis - child |
1,487 |
1,487 |
$48K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,750 |
1,750 |
$20K |
| D0274 |
Bitewings - four radiographic images |
1,004 |
1,003 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
318 |
257 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
424 |
268 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
724 |
718 |
$6K |
| D0272 |
Bitewings - two radiographic images |
505 |
502 |
$5K |
| D1351 |
Sealant - per tooth |
113 |
29 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
293 |
291 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
262 |
261 |
$3K |
| D0350 |
|
437 |
437 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
167 |
166 |
$730.62 |
| D9110 |
|
41 |
41 |
$684.76 |
| D0601 |
|
123 |
123 |
$123.00 |