| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
667 |
652 |
$34K |
| D1110 |
Prophylaxis - adult |
695 |
691 |
$26K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
415 |
336 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
1,045 |
1,022 |
$22K |
| D1120 |
Prophylaxis - child |
641 |
635 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
320 |
236 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
562 |
551 |
$9K |
| D1351 |
Sealant - per tooth |
1,469 |
344 |
$9K |
| D1206 |
Topical application of fluoride varnish |
1,438 |
1,418 |
$7K |
| D0603 |
|
199 |
199 |
$4K |
| D0272 |
Bitewings - two radiographic images |
1,321 |
1,297 |
$3K |
| D9999 |
Unspecified adjunctive procedure, by report |
87 |
87 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,796 |
1,633 |
$2K |
| D0274 |
Bitewings - four radiographic images |
149 |
149 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
1,849 |
1,800 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
59 |
59 |
$641.78 |
| D1330 |
|
702 |
699 |
$60.24 |
| D1310 |
|
1,420 |
1,404 |
$0.00 |