| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
641 |
640 |
$107K |
| D1110 |
Prophylaxis - adult |
1,036 |
1,029 |
$76K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
923 |
606 |
$71K |
| D1120 |
Prophylaxis - child |
1,079 |
1,069 |
$53K |
| D1206 |
Topical application of fluoride varnish |
2,138 |
2,121 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
555 |
555 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
1,446 |
1,433 |
$12K |
| D1351 |
Sealant - per tooth |
972 |
270 |
$10K |
| D1330 |
|
2,106 |
2,091 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
150 |
149 |
$4K |
| D0274 |
Bitewings - four radiographic images |
693 |
686 |
$3K |
| D0272 |
Bitewings - two radiographic images |
34 |
34 |
$563.31 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$12.05 |
| D0601 |
|
47 |
47 |
$0.00 |
| D0603 |
|
17 |
17 |
$0.00 |