| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
172 |
170 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
90 |
53 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
637 |
601 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
200 |
196 |
$9K |
| D1110 |
Prophylaxis - adult |
174 |
173 |
$7K |
| D0274 |
Bitewings - four radiographic images |
192 |
190 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
164 |
158 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
358 |
341 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
141 |
141 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
163 |
160 |
$3K |
| D1351 |
Sealant - per tooth |
48 |
12 |
$1K |
| D1120 |
Prophylaxis - child |
31 |
30 |
$768.42 |
| D1206 |
Topical application of fluoride varnish |
16 |
16 |
$281.76 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$193.50 |