| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
6,125 |
6,125 |
$211K |
| D0330 |
Panoramic radiographic image |
4,015 |
4,012 |
$87K |
| D0120 |
Periodic oral evaluation - established patient |
4,413 |
4,413 |
$86K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,055 |
3,054 |
$65K |
| D1120 |
Prophylaxis - child |
801 |
801 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
538 |
392 |
$18K |
| D0274 |
Bitewings - four radiographic images |
768 |
768 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
983 |
983 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
181 |
146 |
$9K |
| D0272 |
Bitewings - two radiographic images |
755 |
754 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
428 |
428 |
$4K |
| D0350 |
|
395 |
395 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
203 |
203 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
139 |
138 |
$1K |
| D0270 |
|
74 |
74 |
$643.10 |
| D0601 |
|
62 |
62 |
$62.00 |
| D1330 |
|
79 |
79 |
$0.00 |