| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
421 |
419 |
$29K |
| D1110 |
Prophylaxis - adult |
325 |
325 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
101 |
101 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
203 |
97 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
33 |
18 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
229 |
228 |
$3K |
| D1351 |
Sealant - per tooth |
257 |
70 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
30 |
30 |
$694.60 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
53 |
30 |
$563.44 |
| D0120 |
Periodic oral evaluation - established patient |
563 |
562 |
$418.07 |
| D0330 |
Panoramic radiographic image |
24 |
24 |
$235.99 |
| D0274 |
Bitewings - four radiographic images |
220 |
220 |
$43.06 |
| D0220 |
Intraoral - periapical first radiographic image |
237 |
235 |
$36.88 |
| D0272 |
Bitewings - two radiographic images |
387 |
385 |
$15.87 |
| D0230 |
Intraoral - periapical each additional radiographic image |
100 |
81 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
472 |
470 |
$-18.74 |