| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,128 |
1,074 |
$45K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
137 |
133 |
$7K |
| D1110 |
Prophylaxis - adult |
334 |
319 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
810 |
776 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
49 |
38 |
$3K |
| D0274 |
Bitewings - four radiographic images |
247 |
245 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
41 |
31 |
$715.63 |
| D1120 |
Prophylaxis - child |
858 |
811 |
$406.28 |
| D0602 |
|
14 |
12 |
$230.88 |
| D1999 |
|
13 |
13 |
$127.61 |
| D1330 |
|
1,432 |
1,365 |
$80.45 |
| D0330 |
Panoramic radiographic image |
46 |
43 |
$76.30 |
| D0220 |
Intraoral - periapical first radiographic image |
889 |
853 |
$15.00 |
| D1206 |
Topical application of fluoride varnish |
989 |
942 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
107 |
107 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
189 |
186 |
$0.00 |
| D0350 |
|
176 |
160 |
$0.00 |