| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
479 |
478 |
$7K |
| D1110 |
Prophylaxis - adult |
202 |
200 |
$6K |
| D0330 |
Panoramic radiographic image |
129 |
127 |
$5K |
| D0272 |
Bitewings - two radiographic images |
507 |
501 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
111 |
110 |
$3K |
| D1120 |
Prophylaxis - child |
83 |
83 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
105 |
105 |
$2K |
| D1206 |
Topical application of fluoride varnish |
70 |
70 |
$960.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
12 |
$864.00 |
| D0220 |
Intraoral - periapical first radiographic image |
204 |
200 |
$855.00 |
| D0210 |
Intraoral - complete series of radiographic images |
17 |
17 |
$810.00 |
| D0140 |
Limited oral evaluation - problem focused |
19 |
18 |
$338.70 |
| D0230 |
Intraoral - periapical each additional radiographic image |
40 |
13 |
$175.00 |
| D1999 |
|
249 |
245 |
$0.00 |
| D1330 |
|
276 |
274 |
$0.00 |