| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
386 |
386 |
$57K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
898 |
897 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
708 |
705 |
$37K |
| D1351 |
Sealant - per tooth |
2,603 |
566 |
$15K |
| D1330 |
|
1,667 |
1,665 |
$11K |
| D1110 |
Prophylaxis - adult |
545 |
545 |
$7K |
| D1206 |
Topical application of fluoride varnish |
1,630 |
1,627 |
$6K |
| D1120 |
Prophylaxis - child |
962 |
960 |
$5K |
| D9999 |
Unspecified adjunctive procedure, by report |
179 |
176 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
48 |
34 |
$3K |
| D0272 |
Bitewings - two radiographic images |
93 |
93 |
$1K |
| D1999 |
|
22 |
22 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,117 |
327 |
$1K |
| D0330 |
Panoramic radiographic image |
92 |
92 |
$764.50 |
| D0220 |
Intraoral - periapical first radiographic image |
411 |
409 |
$549.46 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$361.18 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$191.10 |
| D0601 |
|
200 |
200 |
$46.75 |
| D0603 |
|
172 |
172 |
$33.75 |
| D0602 |
|
24 |
24 |
$1.00 |