| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
600 |
596 |
$27K |
| D9920 |
|
1,045 |
967 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
276 |
87 |
$11K |
| D0330 |
Panoramic radiographic image |
176 |
173 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
188 |
75 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
183 |
181 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
70 |
70 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
971 |
964 |
$3K |
| D1120 |
Prophylaxis - child |
802 |
796 |
$3K |
| D1330 |
|
1,071 |
1,059 |
$1K |
| D9995 |
|
115 |
115 |
$900.00 |
| D0220 |
Intraoral - periapical first radiographic image |
792 |
785 |
$618.01 |
| D3120 |
|
37 |
14 |
$327.56 |
| D0230 |
Intraoral - periapical each additional radiographic image |
785 |
776 |
$200.10 |
| D0272 |
Bitewings - two radiographic images |
386 |
383 |
$152.85 |
| D0274 |
Bitewings - four radiographic images |
15 |
15 |
$72.52 |