| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
893 |
893 |
$85K |
| D1110 |
Prophylaxis - adult |
928 |
924 |
$61K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,150 |
1,145 |
$57K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
536 |
277 |
$55K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
575 |
227 |
$47K |
| D1330 |
|
1,202 |
1,200 |
$44K |
| D0274 |
Bitewings - four radiographic images |
920 |
917 |
$42K |
| D1206 |
Topical application of fluoride varnish |
1,111 |
1,109 |
$38K |
| D0140 |
Limited oral evaluation - problem focused |
425 |
424 |
$18K |
| D1120 |
Prophylaxis - child |
404 |
404 |
$18K |
| D4355 |
|
120 |
120 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
158 |
158 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
312 |
303 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
26 |
$3K |
| D0272 |
Bitewings - two radiographic images |
43 |
43 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
119 |
78 |
$1K |