| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
882 |
874 |
$46K |
| D0120 |
Periodic oral evaluation - established patient |
383 |
380 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
169 |
107 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
78 |
51 |
$3K |
| D4355 |
|
14 |
14 |
$804.42 |
| D0220 |
Intraoral - periapical first radiographic image |
568 |
564 |
$323.20 |
| D0272 |
Bitewings - two radiographic images |
1,285 |
1,274 |
$287.68 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$188.68 |
| D0330 |
Panoramic radiographic image |
855 |
847 |
$158.12 |
| D1110 |
Prophylaxis - adult |
142 |
141 |
$127.41 |
| D1330 |
|
294 |
290 |
$111.97 |
| D1208 |
Topical application of fluoride, excluding varnish |
228 |
226 |
$77.40 |
| D1120 |
Prophylaxis - child |
33 |
33 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
434 |
431 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
25 |
25 |
$0.00 |