| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,376 |
1,367 |
$9K |
| D1110 |
Prophylaxis - adult |
1,274 |
1,268 |
$9K |
| D1120 |
Prophylaxis - child |
229 |
229 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
639 |
635 |
$2K |
| D0274 |
Bitewings - four radiographic images |
463 |
454 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
1,367 |
1,340 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
169 |
169 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
51 |
51 |
$735.25 |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,160 |
877 |
$524.75 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
45 |
26 |
$168.75 |
| D0140 |
Limited oral evaluation - problem focused |
66 |
66 |
$155.00 |
| D0330 |
Panoramic radiographic image |
30 |
30 |
$0.00 |