| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
45 |
42 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
73 |
44 |
$5K |
| D1206 |
Topical application of fluoride varnish |
89 |
88 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
28 |
28 |
$5K |
| D1351 |
Sealant - per tooth |
255 |
57 |
$4K |
| D1120 |
Prophylaxis - child |
71 |
67 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
48 |
32 |
$3K |
| D0272 |
Bitewings - two radiographic images |
52 |
51 |
$506.25 |
| D0220 |
Intraoral - periapical first radiographic image |
50 |
48 |
$337.50 |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$168.75 |
| D0230 |
Intraoral - periapical each additional radiographic image |
70 |
39 |
$168.75 |
| D0191 |
|
15 |
15 |
$0.00 |
| D0190 |
|
42 |
42 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
31 |
29 |
$0.00 |