| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
450 |
440 |
$25K |
| D1120 |
Prophylaxis - child |
725 |
713 |
$19K |
| D0274 |
Bitewings - four radiographic images |
397 |
391 |
$14K |
| D1110 |
Prophylaxis - adult |
259 |
253 |
$14K |
| D1206 |
Topical application of fluoride varnish |
424 |
412 |
$14K |
| D0330 |
Panoramic radiographic image |
220 |
217 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
696 |
684 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
166 |
165 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
72 |
55 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
101 |
68 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
639 |
217 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
396 |
388 |
$5K |
| D1351 |
Sealant - per tooth |
170 |
57 |
$5K |
| D0272 |
Bitewings - two radiographic images |
183 |
180 |
$903.00 |
| D0210 |
Intraoral - complete series of radiographic images |
28 |
27 |
$639.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
441 |
433 |
$239.00 |