| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
381 |
379 |
$46K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
120 |
120 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
108 |
67 |
$4K |
| D1351 |
Sealant - per tooth |
669 |
175 |
$2K |
| D1110 |
Prophylaxis - adult |
277 |
276 |
$1K |
| D1330 |
|
528 |
519 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
499 |
490 |
$958.93 |
| D1999 |
|
37 |
36 |
$942.58 |
| D0274 |
Bitewings - four radiographic images |
300 |
299 |
$694.43 |
| D0272 |
Bitewings - two radiographic images |
171 |
171 |
$684.22 |
| D1120 |
Prophylaxis - child |
230 |
228 |
$245.97 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
13 |
$159.60 |
| D0603 |
|
64 |
64 |
$130.25 |
| D0220 |
Intraoral - periapical first radiographic image |
470 |
467 |
$126.88 |
| D0230 |
Intraoral - periapical each additional radiographic image |
464 |
445 |
$83.00 |
| D0602 |
|
33 |
33 |
$77.25 |
| D1354 |
|
195 |
74 |
$0.00 |
| D0330 |
Panoramic radiographic image |
84 |
84 |
$0.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
14 |
14 |
$0.00 |