| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
495 |
495 |
$27K |
| D1120 |
Prophylaxis - child |
643 |
641 |
$21K |
| D1110 |
Prophylaxis - adult |
376 |
376 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
864 |
864 |
$14K |
| D1351 |
Sealant - per tooth |
1,304 |
267 |
$10K |
| D1206 |
Topical application of fluoride varnish |
1,165 |
1,162 |
$10K |
| D0274 |
Bitewings - four radiographic images |
409 |
409 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
184 |
130 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
102 |
78 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
237 |
237 |
$5K |
| D9999 |
Unspecified adjunctive procedure, by report |
80 |
80 |
$2K |
| D0272 |
Bitewings - two radiographic images |
484 |
482 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
1,333 |
1,328 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,195 |
1,161 |
$945.07 |
| D1330 |
|
295 |
295 |
$415.00 |
| D0603 |
|
78 |
77 |
$385.00 |
| D9310 |
|
14 |
14 |
$332.00 |
| D0140 |
Limited oral evaluation - problem focused |
33 |
32 |
$331.74 |
| D1310 |
|
1,164 |
1,161 |
$0.00 |
| D9986 |
|
166 |
159 |
$0.00 |