| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,360 |
1,328 |
$104K |
| D0120 |
Periodic oral evaluation - established patient |
626 |
605 |
$44K |
| D4355 |
|
211 |
205 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
143 |
103 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,915 |
1,857 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
143 |
136 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
76 |
53 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
2,073 |
2,007 |
$2K |
| D1351 |
Sealant - per tooth |
671 |
125 |
$2K |
| D1110 |
Prophylaxis - adult |
211 |
208 |
$1K |
| D0330 |
Panoramic radiographic image |
631 |
619 |
$911.04 |
| D1208 |
Topical application of fluoride, excluding varnish |
600 |
584 |
$452.48 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
14 |
$315.68 |
| D0272 |
Bitewings - two radiographic images |
1,775 |
1,721 |
$249.72 |
| D1120 |
Prophylaxis - child |
120 |
116 |
$165.06 |
| D1330 |
|
659 |
639 |
$86.24 |
| D0210 |
Intraoral - complete series of radiographic images |
49 |
49 |
$66.58 |
| D0274 |
Bitewings - four radiographic images |
39 |
38 |
$0.00 |
| D4921 |
|
21 |
17 |
$0.00 |
| D0270 |
|
55 |
52 |
$0.00 |
| D4346 |
|
16 |
16 |
$0.00 |