| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
100 |
100 |
$3K |
| D1110 |
Prophylaxis - adult |
58 |
58 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
129 |
129 |
$2K |
| D1120 |
Prophylaxis - child |
70 |
70 |
$2K |
| D0274 |
Bitewings - four radiographic images |
74 |
74 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
25 |
13 |
$2K |
| D0330 |
Panoramic radiographic image |
31 |
31 |
$2K |
| D1351 |
Sealant - per tooth |
60 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
123 |
123 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
13 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
119 |
119 |
$1K |
| D0272 |
Bitewings - two radiographic images |
38 |
38 |
$746.70 |
| D0120 |
Periodic oral evaluation - established patient |
28 |
28 |
$611.24 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$368.81 |