| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,699 |
2,666 |
$174K |
| D2750 |
|
179 |
138 |
$87K |
| D0330 |
Panoramic radiographic image |
1,522 |
1,497 |
$69K |
| D0120 |
Periodic oral evaluation - established patient |
2,197 |
2,174 |
$67K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,168 |
1,148 |
$64K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,488 |
2,460 |
$58K |
| D0274 |
Bitewings - four radiographic images |
2,160 |
2,128 |
$50K |
| D0140 |
Limited oral evaluation - problem focused |
933 |
924 |
$44K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
242 |
172 |
$33K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
161 |
137 |
$27K |
| D0220 |
Intraoral - periapical first radiographic image |
1,743 |
1,672 |
$20K |
| D1120 |
Prophylaxis - child |
207 |
204 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
349 |
333 |
$4K |
| D0270 |
|
330 |
330 |
$3K |
| D2950 |
|
15 |
12 |
$1K |
| D1330 |
|
141 |
138 |
$828.00 |
| D0272 |
Bitewings - two radiographic images |
38 |
37 |
$590.25 |