| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,387 |
1,346 |
$78K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
192 |
192 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
131 |
129 |
$8K |
| D0999 |
Unspecified diagnostic procedure, by report |
64 |
57 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
94 |
87 |
$4K |
| D1120 |
Prophylaxis - child |
974 |
937 |
$3K |
| D1110 |
Prophylaxis - adult |
209 |
192 |
$3K |
| D0603 |
|
270 |
270 |
$2K |
| D1206 |
Topical application of fluoride varnish |
928 |
901 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
16 |
16 |
$101.18 |
| D0220 |
Intraoral - periapical first radiographic image |
164 |
160 |
$101.18 |
| D0602 |
|
57 |
57 |
$0.00 |
| D1330 |
|
25 |
25 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
97 |
97 |
$0.00 |
| D0601 |
|
44 |
44 |
$0.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
110 |
108 |
$0.00 |
| D0330 |
Panoramic radiographic image |
131 |
130 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
44 |
38 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
145 |
145 |
$0.00 |