| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
512 |
510 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
253 |
252 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
80 |
50 |
$6K |
| D1110 |
Prophylaxis - adult |
352 |
347 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
49 |
27 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
172 |
171 |
$3K |
| D4355 |
|
36 |
36 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
663 |
655 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
103 |
101 |
$1K |
| D1120 |
Prophylaxis - child |
399 |
394 |
$1K |
| D0274 |
Bitewings - four radiographic images |
265 |
261 |
$472.41 |
| D0272 |
Bitewings - two radiographic images |
92 |
91 |
$122.52 |
| D1208 |
Topical application of fluoride, excluding varnish |
713 |
703 |
$119.50 |
| D0251 |
|
160 |
160 |
$96.60 |
| D1330 |
|
969 |
958 |
$93.83 |
| D0220 |
Intraoral - periapical first radiographic image |
720 |
706 |
$33.00 |
| D1206 |
Topical application of fluoride varnish |
145 |
143 |
$19.42 |