| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,050 |
732 |
$14K |
| D1110 |
Prophylaxis - adult |
1,046 |
793 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
902 |
705 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
592 |
208 |
$6K |
| D0330 |
Panoramic radiographic image |
610 |
496 |
$3K |
| D0274 |
Bitewings - four radiographic images |
975 |
810 |
$729.93 |
| D0230 |
Intraoral - periapical each additional radiographic image |
809 |
698 |
$451.75 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
273 |
82 |
$368.00 |
| D0220 |
Intraoral - periapical first radiographic image |
1,089 |
876 |
$345.41 |
| D1120 |
Prophylaxis - child |
212 |
135 |
$340.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
1,359 |
1,024 |
$142.35 |
| D1330 |
|
1,643 |
1,182 |
$124.98 |
| D0210 |
Intraoral - complete series of radiographic images |
310 |
163 |
$98.00 |
| D0140 |
Limited oral evaluation - problem focused |
24 |
15 |
$16.00 |
| D1999 |
|
28 |
28 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
21 |
13 |
$0.00 |
| D1351 |
Sealant - per tooth |
420 |
39 |
$0.00 |