| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
395 |
391 |
$85K |
| D1110 |
Prophylaxis - adult |
441 |
439 |
$47K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
151 |
92 |
$37K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
256 |
131 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
401 |
398 |
$18K |
| D4341 |
|
45 |
13 |
$10K |
| D1330 |
|
683 |
677 |
$10K |
| D0350 |
|
395 |
392 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
155 |
155 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
50 |
47 |
$4K |
| D4355 |
|
12 |
12 |
$3K |
| D0274 |
Bitewings - four radiographic images |
26 |
26 |
$2K |
| D1120 |
Prophylaxis - child |
13 |
13 |
$946.13 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$407.00 |