| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
272 |
271 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
196 |
191 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
115 |
107 |
$4K |
| D1999 |
|
12 |
12 |
$480.00 |
| D0999 |
Unspecified diagnostic procedure, by report |
14 |
14 |
$280.00 |
| D1351 |
Sealant - per tooth |
289 |
91 |
$154.54 |
| D0330 |
Panoramic radiographic image |
84 |
83 |
$88.59 |
| D0240 |
|
36 |
19 |
$23.10 |
| D0272 |
Bitewings - two radiographic images |
157 |
152 |
$13.65 |
| D1208 |
Topical application of fluoride, excluding varnish |
484 |
477 |
$0.00 |
| D1330 |
|
487 |
480 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
17 |
15 |
$0.00 |
| D1120 |
Prophylaxis - child |
423 |
417 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
43 |
43 |
$0.00 |