| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
279 |
277 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
145 |
140 |
$11K |
| D1110 |
Prophylaxis - adult |
119 |
118 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
232 |
229 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
16 |
$794.34 |
| D1999 |
|
17 |
17 |
$680.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
12 |
$388.28 |
| D1120 |
Prophylaxis - child |
91 |
85 |
$42.17 |
| D0274 |
Bitewings - four radiographic images |
80 |
79 |
$26.76 |
| D1208 |
Topical application of fluoride, excluding varnish |
262 |
254 |
$23.35 |
| D0220 |
Intraoral - periapical first radiographic image |
153 |
148 |
$13.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
141 |
127 |
$0.00 |
| D1330 |
|
253 |
245 |
$0.00 |