| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
423 |
420 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
372 |
367 |
$21K |
| D0330 |
Panoramic radiographic image |
403 |
399 |
$15K |
| D1110 |
Prophylaxis - adult |
309 |
307 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
65 |
65 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
38 |
27 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
16 |
$2K |
| D1999 |
|
60 |
51 |
$1K |
| D1351 |
Sealant - per tooth |
806 |
181 |
$1K |
| D1120 |
Prophylaxis - child |
399 |
395 |
$789.00 |
| D0220 |
Intraoral - periapical first radiographic image |
109 |
108 |
$571.25 |
| D9920 |
|
13 |
12 |
$288.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
715 |
710 |
$281.00 |
| D0274 |
Bitewings - four radiographic images |
347 |
346 |
$43.00 |
| D1330 |
|
825 |
816 |
$6.00 |
| D0272 |
Bitewings - two radiographic images |
180 |
180 |
$0.00 |