| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
500 |
481 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
56 |
52 |
$1K |
| D1120 |
Prophylaxis - child |
300 |
287 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
27 |
24 |
$827.61 |
| D1110 |
Prophylaxis - adult |
112 |
105 |
$556.39 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
254 |
120 |
$440.00 |
| D0220 |
Intraoral - periapical first radiographic image |
436 |
393 |
$98.61 |
| D0272 |
Bitewings - two radiographic images |
296 |
285 |
$96.69 |
| D1206 |
Topical application of fluoride varnish |
412 |
400 |
$83.40 |
| D0274 |
Bitewings - four radiographic images |
15 |
14 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
361 |
273 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
353 |
168 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
64 |
64 |
$0.00 |