| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
902 |
902 |
$6K |
| D1110 |
Prophylaxis - adult |
1,045 |
1,045 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
477 |
477 |
$3K |
| D1120 |
Prophylaxis - child |
812 |
812 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
1,576 |
1,576 |
$3K |
| D1206 |
Topical application of fluoride varnish |
1,014 |
1,014 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
647 |
647 |
$1K |
| D0274 |
Bitewings - four radiographic images |
384 |
383 |
$582.00 |
| D1351 |
Sealant - per tooth |
92 |
15 |
$574.00 |
| D0251 |
|
574 |
574 |
$320.00 |
| D0272 |
Bitewings - two radiographic images |
24 |
24 |
$186.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
22 |
13 |
$60.00 |
| D0603 |
|
61 |
61 |
$40.00 |
| D0601 |
|
97 |
97 |
$40.00 |
| D0220 |
Intraoral - periapical first radiographic image |
96 |
95 |
$38.75 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
12 |
$0.00 |
| D2740 |
Crown - porcelain/ceramic |
12 |
12 |
$0.00 |