| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
303 |
294 |
$42K |
| D1206 |
Topical application of fluoride varnish |
467 |
458 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
190 |
182 |
$26K |
| D1351 |
Sealant - per tooth |
1,026 |
228 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
330 |
223 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
306 |
217 |
$18K |
| D1120 |
Prophylaxis - child |
349 |
339 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
283 |
274 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
31 |
26 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
435 |
401 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$2K |
| D1110 |
Prophylaxis - adult |
101 |
98 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
520 |
296 |
$840.10 |
| D0330 |
Panoramic radiographic image |
125 |
123 |
$789.95 |
| D0272 |
Bitewings - two radiographic images |
245 |
232 |
$223.42 |
| D7140 |
Extraction, erupted tooth or exposed root |
33 |
15 |
$195.00 |
| D0274 |
Bitewings - four radiographic images |
113 |
108 |
$59.00 |
| D1354 |
|
80 |
29 |
$0.00 |
| D0190 |
|
199 |
198 |
$0.00 |
| D9993 |
|
35 |
35 |
$0.00 |
| D1310 |
|
99 |
95 |
$0.00 |
| D1353 |
|
124 |
28 |
$0.00 |