| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
295 |
267 |
$10K |
| D1120 |
Prophylaxis - child |
221 |
206 |
$9K |
| D1206 |
Topical application of fluoride varnish |
235 |
218 |
$7K |
| D0274 |
Bitewings - four radiographic images |
336 |
311 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
250 |
222 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
513 |
454 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
278 |
257 |
$5K |
| D1351 |
Sealant - per tooth |
131 |
15 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
448 |
400 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
37 |
12 |
$2K |
| D1110 |
Prophylaxis - adult |
57 |
51 |
$790.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
13 |
$365.64 |