| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
937 |
934 |
$76K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
844 |
842 |
$49K |
| D9430 |
|
1,065 |
1,010 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
581 |
581 |
$30K |
| D0330 |
Panoramic radiographic image |
557 |
555 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,752 |
881 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
697 |
682 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
627 |
625 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
165 |
165 |
$7K |
| D1206 |
Topical application of fluoride varnish |
501 |
500 |
$7K |
| D0274 |
Bitewings - four radiographic images |
239 |
234 |
$5K |
| D1120 |
Prophylaxis - child |
166 |
165 |
$5K |
| D0272 |
Bitewings - two radiographic images |
357 |
357 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
76 |
43 |
$4K |
| D0350 |
|
413 |
207 |
$4K |
| D4341 |
|
35 |
12 |
$2K |
| D4910 |
|
13 |
13 |
$1K |
| D0250 |
|
19 |
17 |
$418.00 |
| D1320 |
|
14 |
14 |
$175.00 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$0.00 |