| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
515 |
510 |
$26K |
| D9995 |
|
522 |
519 |
$22K |
| D1351 |
Sealant - per tooth |
894 |
230 |
$15K |
| D1206 |
Topical application of fluoride varnish |
1,449 |
1,442 |
$13K |
| D0191 |
|
1,598 |
1,586 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
191 |
190 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
94 |
94 |
$3K |
| D1120 |
Prophylaxis - child |
91 |
91 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
39 |
30 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
178 |
178 |
$2K |
| D1110 |
Prophylaxis - adult |
35 |
34 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
222 |
77 |
$2K |
| D0274 |
Bitewings - four radiographic images |
94 |
94 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
29 |
29 |
$1K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$420.00 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$124.20 |
| D0190 |
|
17 |
17 |
$0.00 |
| D1330 |
|
222 |
220 |
$0.00 |