| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
273 |
271 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
47 |
47 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
74 |
29 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
68 |
32 |
$2K |
| D1330 |
|
237 |
236 |
$2K |
| D0272 |
Bitewings - two radiographic images |
85 |
85 |
$990.87 |
| D3120 |
|
33 |
16 |
$804.02 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$392.88 |
| D1208 |
Topical application of fluoride, excluding varnish |
268 |
267 |
$201.00 |
| D1110 |
Prophylaxis - adult |
182 |
180 |
$200.00 |
| D0274 |
Bitewings - four radiographic images |
167 |
166 |
$194.98 |
| D0220 |
Intraoral - periapical first radiographic image |
282 |
280 |
$119.80 |
| D0230 |
Intraoral - periapical each additional radiographic image |
270 |
269 |
$30.00 |
| D1120 |
Prophylaxis - child |
117 |
117 |
$0.00 |
| D0330 |
Panoramic radiographic image |
42 |
41 |
$0.00 |