| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
726 |
711 |
$25K |
| D0330 |
Panoramic radiographic image |
253 |
250 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
257 |
172 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
195 |
176 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
627 |
596 |
$15K |
| D1120 |
Prophylaxis - child |
407 |
398 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
250 |
140 |
$10K |
| D1206 |
Topical application of fluoride varnish |
1,233 |
1,195 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
584 |
575 |
$3K |
| D0274 |
Bitewings - four radiographic images |
426 |
421 |
$2K |
| D1351 |
Sealant - per tooth |
454 |
100 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
14 |
$2K |
| D1330 |
|
1,225 |
1,189 |
$1K |
| D0272 |
Bitewings - two radiographic images |
400 |
392 |
$1K |
| D9999 |
Unspecified adjunctive procedure, by report |
16 |
16 |
$400.00 |
| D0140 |
Limited oral evaluation - problem focused |
35 |
33 |
$317.14 |
| D0220 |
Intraoral - periapical first radiographic image |
379 |
350 |
$63.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
180 |
170 |
$12.00 |
| D9986 |
|
145 |
138 |
$0.00 |