| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
920 |
881 |
$81K |
| D0120 |
Periodic oral evaluation - established patient |
264 |
249 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
230 |
218 |
$30K |
| D1120 |
Prophylaxis - child |
449 |
430 |
$28K |
| D1351 |
Sealant - per tooth |
1,003 |
218 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
237 |
224 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
166 |
104 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
97 |
68 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
340 |
315 |
$4K |
| D0272 |
Bitewings - two radiographic images |
281 |
264 |
$1K |
| D1110 |
Prophylaxis - adult |
51 |
46 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
516 |
292 |
$863.12 |
| D0330 |
Panoramic radiographic image |
44 |
41 |
$166.42 |
| D1310 |
|
158 |
143 |
$0.00 |
| D1353 |
|
125 |
32 |
$0.00 |
| D1354 |
|
37 |
14 |
$0.00 |
| D0190 |
|
764 |
738 |
$0.00 |
| D0191 |
|
19 |
19 |
$0.00 |
| D9993 |
|
134 |
124 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
29 |
27 |
$0.00 |