| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
69 |
69 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
32 |
31 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
36 |
12 |
$519.55 |
| D1110 |
Prophylaxis - adult |
74 |
74 |
$31.95 |
| D0230 |
Intraoral - periapical each additional radiographic image |
41 |
39 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
85 |
84 |
$0.00 |
| D1330 |
|
84 |
83 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
68 |
68 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
43 |
40 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
19 |
19 |
$0.00 |