| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
93 |
93 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
19 |
19 |
$878.75 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
13 |
$760.65 |
| D4355 |
|
12 |
12 |
$433.88 |
| D0272 |
Bitewings - two radiographic images |
126 |
125 |
$173.54 |
| D0220 |
Intraoral - periapical first radiographic image |
111 |
110 |
$150.17 |
| D0230 |
Intraoral - periapical each additional radiographic image |
90 |
89 |
$142.57 |
| D1330 |
|
32 |
31 |
$3.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
16 |
15 |
$0.00 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$0.00 |
| D0330 |
Panoramic radiographic image |
27 |
27 |
$0.00 |