| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,361 |
1,358 |
$51K |
| D0330 |
Panoramic radiographic image |
506 |
504 |
$41K |
| D1110 |
Prophylaxis - adult |
614 |
612 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,685 |
1,683 |
$28K |
| D1120 |
Prophylaxis - child |
1,175 |
1,174 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
379 |
379 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
126 |
94 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
156 |
117 |
$9K |
| D0274 |
Bitewings - four radiographic images |
613 |
613 |
$6K |
| D0272 |
Bitewings - two radiographic images |
722 |
721 |
$5K |
| D1330 |
|
1,847 |
1,844 |
$4K |
| D1351 |
Sealant - per tooth |
184 |
56 |
$4K |
| D1206 |
Topical application of fluoride varnish |
32 |
32 |
$680.32 |
| D9999 |
Unspecified adjunctive procedure, by report |
14 |
14 |
$425.00 |
| D0602 |
|
183 |
183 |
$163.00 |
| D0601 |
|
164 |
164 |
$139.00 |
| D0603 |
|
140 |
140 |
$120.00 |
| D9986 |
|
316 |
311 |
$0.00 |