| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
1,411 |
1,363 |
$76K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,980 |
690 |
$66K |
| D1110 |
Prophylaxis - adult |
2,434 |
2,373 |
$57K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
462 |
265 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
1,550 |
1,511 |
$33K |
| D0250 |
|
669 |
645 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,412 |
1,368 |
$6K |
| D1120 |
Prophylaxis - child |
465 |
449 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,701 |
1,650 |
$4K |
| D1351 |
Sealant - per tooth |
1,022 |
221 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
248 |
128 |
$2K |
| D1330 |
|
1,578 |
1,528 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
2,881 |
2,796 |
$2K |
| D0274 |
Bitewings - four radiographic images |
2,743 |
2,666 |
$2K |
| D2332 |
|
23 |
12 |
$813.28 |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,847 |
2,760 |
$458.03 |
| D0272 |
Bitewings - two radiographic images |
62 |
60 |
$341.12 |
| D3120 |
|
158 |
46 |
$146.08 |
| D0350 |
|
87 |
83 |
$50.00 |