| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
525 |
463 |
$4K |
| D1110 |
Prophylaxis - adult |
418 |
370 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
63 |
31 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
591 |
518 |
$2K |
| D1206 |
Topical application of fluoride varnish |
550 |
495 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
296 |
126 |
$2K |
| D0274 |
Bitewings - four radiographic images |
491 |
432 |
$2K |
| D1120 |
Prophylaxis - child |
198 |
185 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
203 |
186 |
$994.75 |
| D0120 |
Periodic oral evaluation - established patient |
70 |
70 |
$810.42 |
| D1330 |
|
482 |
417 |
$702.26 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
201 |
87 |
$294.44 |
| D1351 |
Sealant - per tooth |
113 |
32 |
$183.36 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
70 |
43 |
$179.30 |
| D0220 |
Intraoral - periapical first radiographic image |
95 |
89 |
$61.05 |
| D0230 |
Intraoral - periapical each additional radiographic image |
26 |
12 |
$28.60 |
| D2394 |
|
16 |
12 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
37 |
27 |
$0.00 |