| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
801 |
764 |
$9K |
| D1120 |
Prophylaxis - child |
576 |
575 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,321 |
1,310 |
$8K |
| D1110 |
Prophylaxis - adult |
434 |
430 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
637 |
633 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
535 |
497 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
1,408 |
1,327 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
442 |
438 |
$5K |
| D0274 |
Bitewings - four radiographic images |
561 |
552 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,098 |
728 |
$3K |
| D0272 |
Bitewings - two radiographic images |
159 |
159 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
13 |
$1K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
23 |
12 |
$856.19 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$58.55 |
| D1999 |
|
159 |
138 |
$0.00 |