| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
910 |
910 |
$7K |
| D1120 |
Prophylaxis - child |
688 |
688 |
$5K |
| D1351 |
Sealant - per tooth |
460 |
76 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
142 |
70 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
656 |
656 |
$2K |
| D0330 |
Panoramic radiographic image |
115 |
115 |
$1K |
| D0274 |
Bitewings - four radiographic images |
355 |
355 |
$1K |
| D1110 |
Prophylaxis - adult |
247 |
247 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
634 |
342 |
$737.00 |
| D0220 |
Intraoral - periapical first radiographic image |
499 |
493 |
$703.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
73 |
73 |
$525.00 |
| D0140 |
Limited oral evaluation - problem focused |
51 |
45 |
$241.30 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
12 |
$176.00 |