| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
466 |
465 |
$45K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
129 |
128 |
$15K |
| D1351 |
Sealant - per tooth |
636 |
155 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
121 |
50 |
$5K |
| D1330 |
|
619 |
617 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
616 |
612 |
$485.61 |
| D0230 |
Intraoral - periapical each additional radiographic image |
610 |
605 |
$105.54 |
| D1120 |
Prophylaxis - child |
231 |
231 |
$92.16 |
| D1208 |
Topical application of fluoride, excluding varnish |
620 |
617 |
$16.35 |
| D1110 |
Prophylaxis - adult |
349 |
348 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
181 |
180 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
368 |
367 |
$0.00 |