| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0274 |
Bitewings - four radiographic images |
2,207 |
2,060 |
$46K |
| D1206 |
Topical application of fluoride varnish |
1,358 |
1,272 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
1,562 |
1,437 |
$32K |
| D1120 |
Prophylaxis - child |
767 |
726 |
$32K |
| D0330 |
Panoramic radiographic image |
938 |
902 |
$31K |
| D0220 |
Intraoral - periapical first radiographic image |
3,426 |
3,150 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
677 |
290 |
$28K |
| D1110 |
Prophylaxis - adult |
745 |
687 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,620 |
2,765 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
609 |
579 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
332 |
329 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
190 |
85 |
$5K |
| D0999 |
Unspecified diagnostic procedure, by report |
60 |
59 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
22 |
22 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
116 |
111 |
$1K |
| D1351 |
Sealant - per tooth |
38 |
15 |
$895.66 |
| D9999 |
Unspecified adjunctive procedure, by report |
28 |
28 |
$560.00 |
| D1999 |
|
12 |
12 |
$180.00 |
| D0270 |
|
12 |
12 |
$117.90 |