| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,026 |
1,026 |
$465.50 |
| D0120 |
Periodic oral evaluation - established patient |
1,576 |
1,576 |
$332.50 |
| D1206 |
Topical application of fluoride varnish |
551 |
551 |
$312.00 |
| D1351 |
Sealant - per tooth |
315 |
67 |
$148.20 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
655 |
481 |
$118.75 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
448 |
357 |
$85.50 |
| D0272 |
Bitewings - two radiographic images |
402 |
402 |
$83.60 |
| D1110 |
Prophylaxis - adult |
1,311 |
1,311 |
$55.10 |
| D0220 |
Intraoral - periapical first radiographic image |
806 |
804 |
$45.60 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
645 |
645 |
$39.55 |
| D0140 |
Limited oral evaluation - problem focused |
183 |
183 |
$25.65 |
| D0274 |
Bitewings - four radiographic images |
645 |
645 |
$0.00 |
| D0180 |
|
15 |
15 |
$0.00 |
| D0270 |
|
56 |
55 |
$0.00 |
| D0330 |
Panoramic radiographic image |
17 |
17 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
314 |
314 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
392 |
391 |
$0.00 |
| D1330 |
|
1,431 |
1,430 |
$0.00 |
| D1310 |
|
507 |
507 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
828 |
824 |
$0.00 |