| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
323 |
322 |
$36K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
63 |
51 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
73 |
48 |
$3K |
| D1330 |
|
339 |
338 |
$836.30 |
| D1351 |
Sealant - per tooth |
145 |
38 |
$542.00 |
| D0220 |
Intraoral - periapical first radiographic image |
349 |
346 |
$194.95 |
| D1208 |
Topical application of fluoride, excluding varnish |
337 |
336 |
$143.35 |
| D0230 |
Intraoral - periapical each additional radiographic image |
341 |
339 |
$87.46 |
| D1110 |
Prophylaxis - adult |
296 |
295 |
$75.75 |
| D0330 |
Panoramic radiographic image |
58 |
57 |
$44.00 |
| D0274 |
Bitewings - four radiographic images |
295 |
294 |
$16.35 |
| D0272 |
Bitewings - two radiographic images |
18 |
18 |
$0.00 |
| D1120 |
Prophylaxis - child |
31 |
31 |
$0.00 |