| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
332 |
327 |
$24K |
| D1110 |
Prophylaxis - adult |
172 |
171 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
186 |
185 |
$17K |
| D1120 |
Prophylaxis - child |
402 |
397 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
125 |
98 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
134 |
107 |
$9K |
| D1351 |
Sealant - per tooth |
448 |
131 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
16 |
15 |
$298.75 |
| D0191 |
|
102 |
101 |
$147.69 |
| D1206 |
Topical application of fluoride varnish |
572 |
566 |
$74.90 |
| D0274 |
Bitewings - four radiographic images |
86 |
86 |
$37.46 |
| D0220 |
Intraoral - periapical first radiographic image |
375 |
360 |
$27.37 |
| D0230 |
Intraoral - periapical each additional radiographic image |
305 |
299 |
$0.00 |
| D1330 |
|
591 |
585 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
222 |
217 |
$0.00 |