| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,455 |
1,376 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
2,264 |
2,130 |
$43K |
| D0330 |
Panoramic radiographic image |
610 |
578 |
$36K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,863 |
1,748 |
$32K |
| D1120 |
Prophylaxis - child |
1,271 |
1,198 |
$29K |
| D0274 |
Bitewings - four radiographic images |
1,054 |
1,000 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
647 |
608 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,854 |
616 |
$15K |
| D1321 |
|
672 |
606 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
172 |
160 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
634 |
619 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
25 |
12 |
$1K |
| D1351 |
Sealant - per tooth |
47 |
12 |
$646.80 |
| D0272 |
Bitewings - two radiographic images |
24 |
24 |
$252.00 |