| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
973 |
898 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
683 |
643 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
249 |
230 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
412 |
377 |
$8K |
| D0274 |
Bitewings - four radiographic images |
280 |
264 |
$6K |
| D1354 |
|
172 |
24 |
$3K |
| D1351 |
Sealant - per tooth |
154 |
14 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
70 |
69 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
381 |
325 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
45 |
14 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
230 |
213 |
$2K |
| D2954 |
|
17 |
12 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
78 |
75 |
$1K |
| D0330 |
Panoramic radiographic image |
19 |
12 |
$361.88 |
| D1206 |
Topical application of fluoride varnish |
19 |
19 |
$330.12 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$330.00 |
| D1330 |
|
39 |
32 |
$263.36 |
| D1310 |
|
39 |
32 |
$259.79 |