| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,146 |
1,135 |
$59K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
119 |
118 |
$8K |
| D0330 |
Panoramic radiographic image |
195 |
194 |
$8K |
| D1110 |
Prophylaxis - adult |
792 |
787 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
114 |
72 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
62 |
42 |
$3K |
| D1120 |
Prophylaxis - child |
403 |
399 |
$2K |
| D1351 |
Sealant - per tooth |
463 |
90 |
$1K |
| D0272 |
Bitewings - two radiographic images |
295 |
294 |
$869.00 |
| D0274 |
Bitewings - four radiographic images |
475 |
471 |
$283.74 |
| D0220 |
Intraoral - periapical first radiographic image |
63 |
61 |
$206.64 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$197.82 |
| D1208 |
Topical application of fluoride, excluding varnish |
1,081 |
1,071 |
$33.00 |
| D1330 |
|
964 |
956 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$0.00 |