| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
891 |
880 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
466 |
465 |
$24K |
| D0210 |
Intraoral - complete series of radiographic images |
707 |
699 |
$17K |
| D1110 |
Prophylaxis - adult |
374 |
372 |
$7K |
| D1351 |
Sealant - per tooth |
465 |
105 |
$4K |
| D1330 |
|
620 |
618 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
48 |
33 |
$3K |
| D8660 |
|
12 |
12 |
$1K |
| D0274 |
Bitewings - four radiographic images |
418 |
415 |
$610.45 |
| D1208 |
Topical application of fluoride, excluding varnish |
643 |
641 |
$525.01 |
| D1120 |
Prophylaxis - child |
254 |
254 |
$409.21 |
| D0999 |
Unspecified diagnostic procedure, by report |
13 |
13 |
$260.00 |
| D0220 |
Intraoral - periapical first radiographic image |
552 |
546 |
$144.12 |
| D0230 |
Intraoral - periapical each additional radiographic image |
555 |
526 |
$96.60 |
| D0330 |
Panoramic radiographic image |
89 |
88 |
$0.00 |