| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
633 |
632 |
$63K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
180 |
180 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
112 |
58 |
$6K |
| D1351 |
Sealant - per tooth |
159 |
50 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
52 |
28 |
$2K |
| D1999 |
|
19 |
19 |
$760.00 |
| D0330 |
Panoramic radiographic image |
309 |
307 |
$451.54 |
| D0220 |
Intraoral - periapical first radiographic image |
641 |
637 |
$426.74 |
| D1120 |
Prophylaxis - child |
516 |
515 |
$423.82 |
| D0272 |
Bitewings - two radiographic images |
345 |
344 |
$296.70 |
| D1208 |
Topical application of fluoride, excluding varnish |
817 |
816 |
$173.45 |
| D1110 |
Prophylaxis - adult |
304 |
304 |
$47.25 |
| D1330 |
|
828 |
827 |
$0.00 |
| D0240 |
|
147 |
92 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
605 |
588 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
300 |
300 |
$0.00 |