| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
678 |
653 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
167 |
71 |
$15K |
| D1120 |
Prophylaxis - child |
190 |
188 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
55 |
55 |
$811.20 |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$701.87 |
| D1110 |
Prophylaxis - adult |
37 |
36 |
$566.28 |
| D0272 |
Bitewings - two radiographic images |
15 |
12 |
$235.80 |
| D9992 |
|
53 |
50 |
$0.00 |
| D9994 |
|
55 |
52 |
$0.00 |
| D9920 |
|
118 |
113 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
85 |
85 |
$0.00 |