| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,363 |
1,348 |
$51K |
| D0330 |
Panoramic radiographic image |
390 |
390 |
$25K |
| D1110 |
Prophylaxis - adult |
1,085 |
1,075 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
140 |
69 |
$8K |
| D1120 |
Prophylaxis - child |
540 |
534 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
207 |
97 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
268 |
268 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,425 |
1,409 |
$4K |
| D0274 |
Bitewings - four radiographic images |
950 |
938 |
$2K |
| D1330 |
|
1,528 |
1,512 |
$2K |
| D0272 |
Bitewings - two radiographic images |
283 |
283 |
$545.12 |
| D1351 |
Sealant - per tooth |
553 |
102 |
$320.86 |
| D7111 |
|
28 |
13 |
$138.55 |
| D3120 |
|
224 |
88 |
$104.49 |
| D0220 |
Intraoral - periapical first radiographic image |
41 |
41 |
$80.30 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$56.28 |